The following guidelines apply to inpatient hospital stays incurred at an in-network or out-of-network facility. The eligibility of benefits is based on the specific plan provisions and/or exclusions.
Description of Hospital
A facility which is:
• is legally operated for the inpatient care and treatment of an illness or injury
• is primarily engaged in providing medical and diagnostics services
• has continuous 24-hour nursing services; and
• has a staff of one or more physicians on-site at all times
It does not mean:
• a rest, nursing, or convalescent home
• a facility or institution primarily for the treatment of alcoholics or drug addicts
• a facility primarily affording custodial care
• a free-standing ambulatory surgical facility that arranges for overnight stays within the facility
Description of Inpatient
An inpatient stay means a confinement in a hospital which results in the hospital making a room and board charge. It also means an overnight stay in an observation unit of a hospital.
To qualify for full benefits, all inpatient hospital stays must be pre-certified according to your plan’s pre-certification program. It is the responsibility of the insured to ensure that a call is made to the pre-certification hotline as follows:
Non-Emergency Hospitalizations – the pre-certification hotline must be called at least 72 hours before an insured is scheduled for a non-emergency or elective service.
Medical Emergency – the pre-certification hotline must be called within 2 business days (or as soon as reasonably possible if the insured’s condition prevents them from calling within that time frame) following an emergency admission.
Pre-certification Phone Number: 800-245-3005
Billing and Reimbursement
The following information is required when filing a bill for an inpatient hospital stay:
• UB-92/UB-04 (if the claim is not electronically filed through the appropriate PPO network)
• Complete itemization and full description of all charges (miscellaneous charges will not accepted)
• Invoicing (to include manufacturer, brand, and model) for any implant charges (revenue code 0278)
• Operative report for operating room charges of $5,000 or greater
• Supply charges
Routine supplies (i.e., admission kits, gloves, IV tubing, etc.) are generally available to all patients and should be included in the standard room and board cost.
Non-routine supplies billed separately from standard room and board will be considered reimbursable when documentation is provided supporting the medical necessity of the supply and that the supply was reasonable for the diagnosis or treatment of the illness and there is documentation to support the delivery to and the use of the supply to the patient for whom it was ordered.
Pekin Life Insurance Company reimburses medically necessary services. The plan will provide reimbursement for hospital room and board at the standard semi-private room rate. A patient may request a private room; however, the insured will be responsible for paying the rate differential. Intensive Care Unit (ICU) charges are covered in full when ordered by the primary physician and the level of care is medically necessary.
General benefit information may be verified by faxing a request to 1-309- 346-8265. The information will be returned by fax within twenty-four (24) working hours.
An insured may be liable for any of the following:
• Usual & Customary disallowed amounts
• Non-covered services