Part 4 – Utilization Review Requirements (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 31 In other cases, based on a medical necessity determination, Blue Cross Blue Shield HMO Blue may determine that you no longer need inpatient coverage in that health care facility. Or, you may no longer need inpatient coverage at all. Blue Cross Blue Shield HMO Blue will make this decision within one working day of receiving all necessary information. Blue Cross Blue Shield HMO Blue will call the health care facility to let them know of this decision. Blue Cross Blue Shield HMO Blue will discuss plans for continued coverage in a health care setting that better meets your needs. This phone call will be made within 24 hours of the Blue Cross Blue Shield HMO Blue coverage decision. For example, your condition may no longer require inpatient coverage in a hospital, but it still may require skilled nursing coverage. If this is the case, your physician may decide to transfer you to a skilled nursing facility. Any proposed plans will be discussed with you by your physician. All arrangements for discharge planning will be confirmed in writing with you. Blue Cross Blue Shield HMO Blue will send this written (or electronic) notice to you and to the facility within one working day of that phone call to the facility. You may choose to stay in the health care facility after you have been told by your health care provider or Blue Cross Blue Shield HMO Blue that inpatient coverage is no longer medically necessary. But, if you do, Blue Cross Blue Shield HMO Blue will not provide any more coverage (except as otherwise may be required during the formal review process). You must pay all costs for the rest of that inpatient stay. This starts from the date the written notice is sent to you from Blue Cross Blue Shield HMO Blue. Reconsideration of Adverse Determination Your health care provider may ask that Blue Cross Blue Shield HMO Blue reconsider its decision when Blue Cross Blue Shield HMO Blue has determined that continued inpatient coverage is not medically necessary for your condition. In this case, Blue Cross Blue Shield HMO Blue will arrange for the decision to be reviewed by a clinical peer reviewer. This review will be held between your health care provider and the clinical peer reviewer. And, it will be held within one working day of the date that your health care provider asks for the Blue Cross Blue Shield HMO Blue decision to be reconsidered. If the initial decision is not reversed, you (or the health care provider on your behalf) may ask for a formal review. The process to ask for a formal review is described in Part 10 of this Subscriber Certificate. You may request a formal review even if your health care provider has not asked that the Blue Cross Blue Shield HMO Blue decision be reconsidered. Individual Case Management Individual Case Management is a flexible program for managing your benefits in some situations. Through this program, Blue Cross Blue Shield HMO Blue works with your health care providers to make sure that you get medically necessary services in the least intensive setting that meets your needs. Under this program, coverage may be approved for services that are in addition to those that are already covered by this health plan. For example, Blue Cross Blue Shield HMO Blue may approve these services to:  Shorten an inpatient stay. This may occur by sending a member home or to a less intensive setting to continue treatment.  Direct a member to a less costly setting when an inpatient stay has been proposed.  Prevent future inpatient stays. This may occur by providing coverage for outpatient care instead. Blue Cross Blue Shield HMO Blue may, in some situations, present a specific alternative treatment plan to you and your attending physician. This treatment plan will be one that is medically necessary for you. Blue Cross Blue Shield HMO Blue will need the full cooperation of everyone involved. This includes: the patient (or the guardian); the hospital; the attending physician; and the proposed health care provider. Blue Cross Blue Shield HMO Blue may require that there be a written agreement between the patient (or the patient’s family or guardian) and Blue Cross Blue Shield HMO Blue. Blue Cross Blue Shield HMO