The prenotification process is a crucial aspect of a Liberty HealthShare membership, designed to help members navigate their healthcare needs effectively. Understanding when and how to utilize this process can ensure that healthcare services align with the Sharing Guidelines, confirming the eligibility of upcoming needs, sharing limits, and addressing any pre-existing conditions.
Why Prenotification is Essential
Prenotification is especially vital before undergoing any significant medical procedures or diagnostic tests. This includes MRIs, PET scans, endoscopies, surgeries, hospitalizations, pregnancies, oncology needs, and more. To prevent unexpected out-of-pocket expenses, members are encouraged to reference the Sharing Guidelines before scheduling any medical services.
The Prenotification Process in Four Easy Steps
- Familiarize Yourself with the Sharing Guidelines: Before any healthcare need arises, it is essential for members to read and understand the Sharing Guidelines. This document provides a clear understanding of which expenses are eligible for sharing within the community and which are not.
- Submit a Prenotification Request: If the Sharing Guidelines indicate that a medical service requires prenotification, members or their providers must complete and submit the Electronic Prenotification form. This form can be downloaded from the Liberty HealthShare website. For urgent requests, it is advisable to contact the Prenotification Department directly.
- Provide Additional Documentation if Needed: After submitting a prenotification request, the prenotification team may need additional clinical documentation to determine eligibility. This could include information on the onset of signs and symptoms or details about any pre-existing conditions. A nurse specialist will reach out to the member if more information is required.
- Receive a Prenotification Determination: Once the necessary documentation is reviewed, the ministry follow up with the member within 7-10 business days with a prenotification determination. This response will clarify whether the upcoming medical services are eligible for sharing.
Submitting a Prenotification Request
There are two primary ways for members or providers to submit a prenotification request:
- Electronic Prenotification: The electronic prenotification form is accessible to both members and providers at libertyhealthshare.org under the Resources tab. Members can also find this form in their ShareBox. This method ensures quick and efficient processing of requests. The completed form should be faxed or emailed to the Prenotification Department, and confirmation of receipt will be provided within 24 hours.
- Urgent Requests: For urgent medical needs, members or providers should contact the Prenotification Department directly at 855-585-4237. A nurse specialist will assist promptly in managing the medical needs.
Researching and Comparing Healthcare Services
In addition to contacting the prenotification department before receiving services, members are encouraged to research and compare related services to ensure they receive quality care at a fair price. Utilizing resources like HST Connect, accessible within the ShareBox, can provide valuable insights as a self-pay patient, helping to reduce healthcare costs for the entire community.
Prenotification Requirements
Certain medical services require pre-notification to be eligible for cost-sharing. These include:
- Inpatient Hospital Confinements: This includes emergency admissions, skilled nursing, inpatient rehabilitation facilities, and hospice. Any facility admission or confinement lasting more than 23 hours must be prenotified.
- Organ/Tissue Transplant Services
- Extended Emergency Department Observation Periods
- Home Health Care Services
- Outpatient Surgery: Including surgical centers, clinics, and hospitals.
- Maternity, Obstetric, and Prenatal Needs: Members must notify the Prenotification Department upon learning of pregnancy to establish eligibility.
- Non-emergent MRI Scans
- PET Scans
- Cardiac Rehabilitation
- Chemotherapy or Radiation Therapy
- Pain Injections/Pain Management
- Outpatient Infusion Therapy
- Invasive Diagnostic Testing: Involving puncturing the skin or entering the body in an outpatient or surgical setting.
Utilizing Healthcare Resources
The ministry provides various healthcare resources to assist members in making informed choices and reducing healthcare costs. The expansive PHCS network of providers is one such resource, offering members access to a broad range of medical professionals.
Additionally, the Care Navigation team is available to help guide members through their healthcare choices. The combined efforts of the prenotification process and the Care Navigation team ensure that members understand the Sharing Guidelines, the eligibility of upcoming medical needs, program sharing limits, and pre-existing conditions.
Prenotification advises members whether their planned medical care is eligible for sharing. It is not a determination that it has been approved for sharing.
The prenotification process at the ministry is designed to empower members to make informed healthcare decisions while adhering to the community’s Sharing Guidelines. By following the steps outlined above and utilizing available resources, members can navigate their healthcare needs with confidence and ensure that their medical expenses are eligible for sharing. For any questions or further assistance, members are encouraged to contact the Prenotification Department, where dedicated nursing staff are ready to help.