Non-certification of Medical Necessity
If Acentra determines services are not medically necessary, or are being provided at a level of care inconsistent with the standard form of managed care environments, Acentra will advise the participant and/or the treating provider that coverage cannot be guaranteed.
No benefits will be provided for any service related to an inpatient hospital admission or specified outpatient diagnostic test that is determined by Acentra (either before or after the admission) not to be medically necessary.
Retrospective Review
If Acentra is not notified of an inpatient admission or outpatient diagnostic test, a retrospective review may be performed. A retrospective review may be performed when Acentra is contacted after discharge from an inpatient admission or more than 48 hours after a specified outpatient diagnostic test was performed. Even if Acentra determines that services are medically necessary, financial penalties will apply.