Medical Policy | Pre-certification | Prior Authorization

Medical Policy Terms of Use:

PreferredOne
Medical Policies Agreement

READ the following terms and conditions. If you agree to them, click on 'Accept Terms' below. If you do not agree to these terms, click on 'Decline' and you will be returned to the PreferredOne home page.

Medical policies accessible through this site serve as a guide for use in making benefit coverage recommendations or determinations or in evaluating the medical necessity of services for enrollees of:

a.  PreferredOne Community Health Plan (PCHP), a health maintenance organization;

b.  certain self-funded plans administered by PreferredOne Administrative Services, Inc. (PAS), a third-party administrator; and

c.  benefit plans receiving certain services from PreferredOne, a preferred provider organization.

Enrollees in PreferredOne Community Health Plan (PCHP) and some non-ERISA group health plans that PreferredOne Administrative Services, Inc. (PAS) administers are eligible to receive all benefits mandated by the state of Minnesota.

These medical policies do not constitute or serve as a substitute for medical treatment or advice, nor do they constitute or serve as a substitute for the exercise of independent medical judgment in enrollee specific matters. They are intended to promote objectivity and consistency in the health care coverage decision-making process and are necessarily general in approach. Therefore, medical discretion must be exercised in their application. Additional information may be required and requested by PCHP before coverage determinations or recommendations can be made.

Benefits are available to enrollees only for covered services specified in the enrollee's benefit plan document. Benefits are not available if a service is excluded by a health plan from coverage. Exclusions from coverage typically include, but are not limited to, health care services that are not medically necessary as determined by the Plan Administrator or its designee. Final coverage determinations are based on the applicable plan language. To the extent there is any inconsistency between a medical policy set forth on this site and the terms of an enrollee's benefit plan, the terms of the enrollee's benefit plan will always control.

Please call the Customer Service telephone number listed on the back of the enrollee's identification card for applicable pre-certification/notification requirements and/or to obtain paper copies of policies included in this web site.