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Online Precertification Agreement
All users of IMG®'s online Precertification feature understand and agree that the
online Precertification Form is made available and is to be used solely in an effort to
expedite and assist the Precertification process.
Online use and submission of the Precertification Form will not automatically
provide a Precertification number or certifiy a request. Upon submission the user will
be notified by email of IMG's receipt of the Form, and the user will subsequently be
contacted by IMG’s subsidiary (and URAC accredited) medical management
company, Akeso® Care Management®, Inc. (ACM®), to complete the Precertification
process.
The user understands and agrees that Precertification is only a determination of
Medical Necessity, and that such determination is made in reliance and based upon
the completeness and accuracy of the information provided by the user, the insured,
and/or the insured's relatives, guardians and/or healthcare providers at the time of
Precertification.
Precertification is neither an assurance, authorization or verification of coverage, a
verification of eligible benefits, or a guarantee of payment, nor is it a denial of such
matters. The fact that Treatment, services or supplies are certified does not
guarantee either the payment or reimbursement of benefits or the amount or
eligibility of benefits.
Any consideration and/or determination of a Precertification request, as well as any
subsequent review or adjudication of all medical claims and invoices submitted in
connection therewith, will remain subject to all terms and conditions of the Insured's
insurance Certificate, including exclusions and/or limitations for Pre-existing
Conditions (as applicable) and other designated exclusions, benefit limitations, and
the requirement that claims be Usual, Reasonable and Customary. No consideration
or determination of a Precertification request will be deemed or considered as an
approval, authorization, or ratification of, recommendation for, or consent to any
diagnosis or proposed course of Treatment. Neither the Company (as insurance
carrier), IMG (as Plan Administrator, nor ACM (as the medical management
company), nor anyone acting on their respective behalfs, has any authority or
obligation to select Physicians, Hospitals or other healthcare providers for the
lnsured Person, or to make any diagnosis or medical Treatment decisions on behalf
of the lnsured Person, and all such decisions must be made solely and exclusively
by the lnsured Person and his/her family members, guardians, and treating
Physicians and other healthcare providers.
If the lnsured Person and/or his/her provider(s) comply with the Precertification
requirements of the insurance Certificate, and the Treatment, services or supplies
are certified by ACM as Medically Necessary, the Company will reimburse the
lnsured Person for Eligible Medical Expenses incurred in relation thereto, subject to
all Terms of the Master Policy and Certificate, including any applicable Deductible
and Coinsurance.
Every attempt will be made to help the lnsured Person and his/her healthcare
providers understand the status, scope and extent of available benefits and
coverages under the Master Policy as outlined in the Certificate; provided, however,
that no statement made by any agent, employee or representative of the Company,
the Plan Administrator or ACM will be deemed or construed as an estoppel or to
create any liability against the Company, the Plan Administrator or ACM, or be
deemed or construed to bind the Company, the Plan Administrator or ACM or to
modify, replace, waive, extend or amend any of the Terms of the Master Policy or
the Certificate, unless expressly set forth in writing.
Actual eligibility determinations, final coverage decisions, and benefit or claim
payments and/or reimbursements can only be determined and adjudicated at the
time a proper and complete Proof of Claim is submitted, an opportunity for
reasonable investigation and/or review is provided, required cooperation received,
and all facts and supporting information, including relevant medical records, are
presented in writing. The Terms of the Master Policy govern all available coverages,
eligibility and payments made or to be made.
If a definite answer to a specific benefits or coverage question is required for any
reason, the lnsured Person or his/her provider may submit a written request to IMG
in that regard, including all pertinent medical information and a statement from the
attending Physician (if applicable), and a written reply will be sent by IMG on behalf
of the Company and kept on file. If IMG on behalf of the Company elects to verify
generally and/or preliminarily to a provider or the lnsured Person that an Injury,
Illness, diagnosis or proposed course of Treatment is or may be covered under the
Master Policy, or that benefits for same are or may be available as outlined in the
insurance Certificate, any such verification of benefits does not guaranty either
payment or reimbursement of benefits or the amount or eligibility of benefits. Final
eligibility determinations, coverage decisions, and actual reimbursement or payment
of claims or benefits are subject to all Terms of the Master Policy and Certificate,
including without limitation filing a proper and
complete Proof of Claim in accordance with the requirements outlined in the
Certificate.
As used herein, the terms "Certificate," "Coinsurance," "Company," "Deductible,"
"Eligible Medical Expenses," "Hospital," "Illness," "Injury," "lnsured Person," "Master
Policy," "Medical Necessity (Medically Necessary)," "Physician," "Plan
Administrator," "Precertification (Precertify)," "Pre-existing Condition," "Proof of
Claim," "Terms," "Treatment," and "Usual, Reasonable and Customary," shall have
the respective meanings and definitions ascribed to them in the applicable certificate
wording (available to any insured or provider upon request).
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