Our medical management company, Spectrum Review Services, Inc. (SRS) wants to familiarize you with the program your employer has selected as a benefit to you. SRS’s goal is to maximize your medical benefits and reduce out of pocket expense. SRS and your employer want to assure you and your covered dependents of receiving necessary, cost-effective and high quality medical care. Although the review of your care is conducted by SRS’s professional team of medical reviewers in conjunction with your doctor, your help is vital in making the SRS program work best for you. Please review the following guidelines of the program for your participation.

BEFORE HOSPITALIZATION . . . . . . .

When your doctor recommends a hospital admission for you or your covered dependent(s) please follow these important steps

1. Inform your doctor that your health benefit plan requires SRS prior approval for all planned, elective hospital admissions.

2. Have your health plan ID card available and follow the instructions for obtaining our toll free telephone number.

SRS NATIONWIDE TOLL FREE NUMBER
(800) 258-5055

You or your doctor must contact SRS at the number listed above (in greater Houston the local number is (281) 444-2194) Monday through Friday from 7:00 AM to 6:00 PM (Central Time). A professional answering service is available during non-office hours. SRS will be back in tough with you the next working day.

3. You or your doctor must call SRS for prior hospital admission approval, ideally 14 days in advance of planned, elective admissions or 48 hours in advance for urgent, non-emergency admissions. It is the employee’s responsibility to make sure that SRS is notified prior to admission and before medical expenses are incurred. Please refer to your health plan document or ask your benefits manager for details.

4. You, your doctor, the hospital and claims payor will be informed of SRS’s determination of medical necessity. SRS only makes a recommendation to your claims payor in regard to medical necessity and does not determine benefits or eligibility for services. You, your doctor and/or your hospital will be informed verbally by phone of our determination. You will also receive a letter in that regard.

5. If you or your covered dependent(s) are admitted to the hospital through the hospital emergency room, SRS should be notified by the next working day.

REMEMBER: You must follow these steps in order to be eligible for benefits allowable under your health benefit plan. If you have any questions regarding your plan, please contact your benefits manager or claims payor.

SRS DOES NOT GUARANTEE HEALTH PLAN ELIGIILITY OR PAYMENT OF MEDICAL EXPENSES

BEFORE A SURGICAL PROCEDURE IS PERFORMED . . . . .

Surgery is an important and costly step in your medical care. Some studies have shown that a number of unnecessary procedures are performed each year. If your doctor recommends a non-emergency surgical procedure, you or your doctor must notify SRS prior to proceeding with the inpatient or outpatient procedure.

The information you will receive from SRS will allow you to make an informed decision.

CONTINUED HOSPITAL STAY . . . . .

SRS will be monitoring your entire hospitalization. If your hospital stay must be extended beyond the usual number of days for your diagnosis or procedure, SRS will consult with your attending physician to determine the medical need for a continued hospital stay.

IF YOU ARE PREGNANT . . . .

As soon as you know of your pregnancy, please give SRS a call so that we may pre-approved your future hospital needs. During that call SRS will do a quick assessment of your health status to determine the possibility of High Risk Pregnancy.

Please remember to notify SRS of any hospitalization, inpatient/outpatient procedure and pregnancy. If SRS is not notified, you may incur reduced health plan benefits and become responsible for a larger part of your medical costs.