Citi Benefits Handbook
Precertification for Oxford Health Plans PPO
The following are examples of services that require precertification. Be sure to contact Oxford Health for a complete list.
- Non-emergency ambulance services for inter-facility transfers;
- Chiropractic services;
- Dental services (accident only);
- Durable medical equipment with a retail cost of more than $500 whether for purchase or rental;
- Hospital and other facility admissions;
- Home health care services, including private-duty nursing;
- Infertility services;
- Reconstructive procedures;
- Hospice care;
- Maternity admissions exceeding 48 hours for normal delivery/96 hours for cesarean section;
- Outpatient hospital, outpatient rehabilitation, ambulatory surgical centers and bariatric surgery;
- Short-term rehabilitation (PT, OT, ST);
- ABA — applied behavior analysis;
- Transplant services; and
- Gender reassignment surgery.
In-network services: Your PCP or other in-network provider will handle the precertification process for you when you receive any in-network services.
Out-of-network services: When you receive care from an out-of-network provider, you must obtain precertification before receiving any of the listed services (your out-of-network provider does not obtain precertification for you).
For inpatient confinement in a hospital or other facility, you must precertify the scheduled admission date at least five days before the start of the confinement. An admission date may not have been set when the confinement was planned. You must call Oxford again as soon as the admission date is set. You must receive precertification for:
- A scheduled hospital admission, including to a mental health or substance abuse treatment facility;
- A scheduled admission to a skilled nursing facility or hospice care facility;
- Home health care; and
- Private-duty nursing.
Outpatient Surgery/Diagnostic Testing/Other Services
When you receive care from an out-of-network provider, you must obtain precertification before receiving the following services:
- Diagnostic tests for organ or tissue transplants;
- Reconstructive procedures;
- Home health care;
- Infertility services, including diagnosis and treatment;
- Private-duty nursing;
- Dental services (accident only); and
- Durable medical equipment with a purchase or cumulative rental cost of $500 or more.
For outpatient services that require precertification, you must receive precertification as soon as reasonably possible.
Mental Health/Substance Abuse
You must obtain precertification before you obtain covered inpatient mental health and/or substance abuse treatment.
You must obtain precertification before the scheduled date of any of the following, or as soon as reasonably possible:
Pregnancy is subject to the following precertification time periods:
- Precertification should be requested through Oxford during the first trimester (12 weeks) of pregnancy; this early notification makes it possible for the mother to participate in a prenatal program;
- For inpatient care (for either the mother or child) that continues beyond 48 hours following a normal vaginal delivery or 96 hours following a cesarean section, Oxford must receive a precertification request before the end of these time periods; and
- Non-emergency inpatient confinement during pregnancy but before the admission for delivery requires precertification as a scheduled confinement.
If you or your physician does not agree with Oxford's determination, you may appeal the decision. For information about the claims appeal process, see "Claims and Appeals for Oxford Health Plans Medical plan."