CONCURRENT REVIEW AND CASE MANAGEMENT Sample Clauses

CONCURRENT REVIEW AND CASE MANAGEMENT. As part of the Precertification process described above, the Plan will determine an “expected” or “typical” length of stay or course of treatment based upon the medical information given to the Plan at the time of your Precertification request. These estimates are used for a concurrent review during the course of your admission or treatment in order to determine if Benefits are eligible in accordance with the Medical Necessity provisions of this Contract. Whenever it is determined that Inpatient care or an ongoing course of treatment may no longer be Medically Necessary, the Plan’s Medical and Benefits Administration staff will contact you, your Provider or other authorized representative to discuss the Medical Necessity guidelines used to determine Benefits for continuing services. When appropriate, the Plan will inform you and your Providers whether additional Benefits are available for services you and your Physician may choose to obtain in an alternate treatment setting. If you or your Provider request to extend care beyond the approved time limit, and it is a Request Involving Urgent Care, the Plan will notify you of its decision within 24 hours, provided the request is made within 24 hours prior to the expiration of the prescribed period of time or course of treatment.