51 • Any Medically Necessary acquisition procedures, mobilization, collection and storage. It also includes Medically Necessary myeloablative or reduced intensity preparative chemotherapy, radiation therapy, or a combination of these therapies, Approved In - Network Provider A Provider who has entered into an agreement with us to provide Covered Procedures to you. The agreement may only cover c ertain Covered Procedures or all Covered Procedures. Approved In - Network Providers may include the following: • Blue Distinction Center (BDC) Facility : Blue Distinction facilities have met or exceeded national quality standards for care delivery of Covered Procedures. • Centers of Medical Excellence (CME) Facility: Centers of Medical Excellence facilities have met or exceeded quality standards for care delivery of Covered Procedures. All Other Providers Any Provider that is NOT an Approved In - Network Provider. This includes In - Network Providers who participate in the Plan’s networks, but who are not an Approved In - Network Provider for a Covered Procedure , as well Out - of - Network Providers. Prior Approval and Precertification To maximize your benefits, you should call our Transplant Department as soon as you think you may need a Covered Procedure to talk about your benefit options. You must do this before you receive services. We will help you maximize your benefits by giving you coverage information, including details on what is covered as well as information on any clinical coverage guidelines, medical policies, Approved In - Network Provider rules, or Exclusions that apply. Call the Member Services phone number on the back o f your Identification Card and ask for the transplant coordinator. You or your Provider must call our Transplant Department for Precertification prior to the Covered Procedure whether this is performed in an Inpatient or Outpatient setting. Your Doctor must certify, and we must agree, that the Covered Procedure is Medica lly Necessary. Your Doctor should send a written request for Precertification to us as soon as possible to start this process. Not getting Precertification will result in a denial of benefits. Please note that there are cases where your Provider asks for approval for Human Leukocyte Antigen (HLA) testing, donor searches and/or a collection and storage of stem cells prior to the final decision as to what Covered Procedure will be needed. In thes e cases, the HLA testing and donor search charges will be covered as routine diagnostic tests. The collection and storage request will be reviewed for Medical Necessity and may be approved. However, such an approval for HLA testing, donor search and/or c ollection and storage is NOT an approval for the later Covered Procedure. A separate Medical Necessity decision will be needed for the Covered Procedure. Transportation and Lodging The Plan will cover the cost of reasonable and necessary travel costs when you get prior approval and need to travel more than 75 miles from your permanent home to reach the Facility where the Covered Procedure will be performed. Help with travel costs in cludes transportation to and from the Facility and lodging for the patient and one companion. If the Member receiving care is a minor, then reasonable and necessary costs for transportation and lodging may be allowed for two companions. You must send ite mized receipts for transportation and lodging costs in a form satisfactory to us when claims are filed. Call us for complete information or refer to IRS Publication 502 .
Benefit Booklet: Plan 1 Page 51 Page 53