35 Getting Approval for Benefits Your Plan includes the process of Utilization Review to decide when services are Medically Necessary or Experimental/Investigational as those terms are defined in this Booklet . Utilization Review aids the delivery of cost - effective health care by reviewing the use of treatments and, when proper, level of care and/or the setting or place of service that they are performed. Reviewing Where Services Are Provided A service must be Medically Necessary to be a Covered Service. When level of care, setting or place of service is reviewed, services that can be safely given to you in a lower level of care or lower cost setting / place of care, will not be Medically Nece ssary if they are given in a higher level of care, or higher cost setting / place of care. This means that a request for a service may be denied because it is not Medically Necessary for the service to be provided where it is being requested. When this ha ppens the service can be requested again in another place and will be reviewed again for Medical Necessity. At times a different Provider or Facility may need to be used in order for the service to be considered Medically Necessary. Examples include, but are not limited to: • A service may be denied on an inpatient basis at a Hospital but may be approvable if provided on an outpatient basis at a Hospital. • A service may be denied on an outpatient basis at a Hospital but may be approvable at a free - standing imaging center, infusion center, Ambulatory Surgery Center, or in a Physician’s office. • A service may be denied at a Skilled Nursing Facility but may be approvable in a home setting. Utilization Review criteria will be based on many sources including medical policy and clinical guidelines. Anthem, on behalf of the Employer, may decide that a treatment that was asked for is not Medically Necessary if a clinically equivalent treatment that is more cost effective is available and appropriate. “Clinically equivalent” means treatments that for most Members, will give you similar r esults for a disease or condition. If you have any questions about the Utilization Review process, the medical policies, or clinical guidelines, you may call the Member Services phone number on the back of your Identification Card. Coverage for or payment of the service or treatment reviewed is not guaranteed even if we decide your services are Medically Necessary. For benefits to be covered, on the date you get service : 1. You must be eligible for benefits; 2. Fees must be paid for the time period that services are given; 3. The service or supply must be a Covered Service under your Plan; 4. The service cannot be subject to an Exclusion under your Plan; and 5. You must not have exceeded any applicable limits under your Plan. Types of Reviews • Pre - service Review – A review of a service, treatment or admission for a benefit coverage determination, which is done before the service or treatment begins or admission date. - Precertification – A required Pre - service Review for a benefit coverage determination for a service or treatment. Certain services require Precertification in order for you to get benefits. The benefit coverage review will include a review to decide whether the service meets the definition of Medical Necessity or is Experimental / Investigational as those terms are defined in this Booklet. For admissions following Emergency Care, you, your authorized representative or Doctor must tell us of the admission as soon as possible . For childbirth admissions, Precertification is not