Mainly Health Plans SL
5. Pre-authorisation ( Guide )
This section contains rules and information about what pre-authorisation means and how it works.
5.1 What pre-authorisation means April 2009 updates
If we pre-authorise your treatment, this means that we will pay up to the limits of your plan provided that all of the following requirements are met:
* the treatment is eligible treatment that is covered by your plan
* you have an active membership at the time that treatment takes place
* your subscriptions are paid up to date
* the treatment carried out matches the treatment authorised
* you have provided a full disclosure of the condition and treatment required
* you have enough benefit entitlement to cover the cost of the treatment
* your condition is not a pre-existing condition ( see Section 3. "What is not covered?" )
* the treatment is medically necessary
* the treatment takes place within 31 days after pre-authorisation is given.
5.2 Treatment we can pre-authorise April 2009 updates
We can pre-authorise in-patient and day-case treatment, cancer treatment and MRI, CT or PET scans.
5.3 Length of stay (in-patient treatment) April 2009 updates
Your pre-authorisation will specify an approved length of stay for in-patient treatment. This is the number of days in hospital that we will cover you for. If your treatment will take longer that this approved length of stay then you or your consultant must contact us for an extension to the pre-authorisation.
5.4 Treatment in the USA April 2009 updates
All in-patient and day-case treatment, cancer treatment and MRI, CT or PET scans in the USA must be pre-authorised. If you are going to receive any of these treatments, ask your medical provider to contact Bupa for pre-authorisation. All the information they need is on your membership card.
We have made special arrangements if you need to be hospitalised in the USA. These include access to a select network of quality medical providers and direct settlement of all covered expenses when you receive treatment in a network hospital.
Treatment which has not been pre-authorised April 2009 updates
If you choose not to get your treatment pre-authorised, we will only pay 50 percent towards the cost of covered treatment.
Of course we understand that there are times when you cannot get your treatment pre-authorised, such as in an emergency. If you are taken to hospital in an emergency it is important that you arrange for the hospital to contact us within 48 hours of your admission. We can then make sure you are getting the right care, and in the right place. If you have been taken to a hospital which is not part of the network and, if it is the best thing for you, we will arrange for you to be moved to a network hospital to continue your treatment once you are stable.
If we have been notified within 48 hours of an emergency admission to hospital, we will not ask you to share the cost of your treatment.
Out of network treatment April 2009 updates
If your treatment has been pre-authorised, but you choose not to go to a network hospital, we will only pay 80 percent towards the cost of covered treatment.
There may be times when it is not possible for you to be treated at a network hospital. These include:
* There is no network hospital within 30 miles of your address
* The treatment you need is not available in the network hospital
In these cases, we will not ask you to share the cost of your treatment.
5.5 Important rules April 2009 updates
Please note that pre-authorisation is only valid if all the details of the authorised treatment, including dates and locations, match those of the treatment received. If there is a change in the treatment required, if you need to have further treatment, or if any other details change, then you or your consultant must contact us to pre-authorise this separately. We make our decision to approve your treatment based on the information given to us. We reserve the right to withdraw our decision if additional information is withheld or not given to us at the time the decision is being made.
Lifeline:
* provides international private medical insurance for people living or working abroad for at least six months of the year
* for individuals and their families
* three different levels of cover to meet any client's needs:
| Product description (and limits) | |
| Essential | Essential |
| Classic | Classic |
| Gold | Gold |
Company Scheme (Castellano Deutsch Français Português)
| For more information please contact me: | |
| davidharris@wanadoo.es / saniprof@mail.ddnet.es | |
| Fax: | (+ 34) 91 8032484 |
| 'phone: | (+ 34) 609 522 300 |
| Also more information on.. | www.e-healthinsuranceservices.com |
| Lifeline Essential | Lifeline Classic |
| Lifeline Gold |