IMG Precertification

Getting the most from your insurance coverage

Thank you for your cooperation in using the precertification process administered by International Medical Group^®, Inc. (IMG^®) and implemented by its subsidiary, Akeso Care Management^SM, Inc. (ACM^SM). This pamphlet contains important information regarding this process. Please review this material carefully, and should you have questions, please contact us via the information provided on the back panel of this pamphlet. We appreciate your business and strive to make the medical process a smooth one for you.

Under the Terms of your insurance plan, precertification is only a determination of Medical Necessity, and all such determinations are made in reliance on the completeness and accuracy of the information provided by you and your healthcare providers at the time of precertification. In your Certificate, the Company has reserved the right to challenge or revoke ACM's determination of Medical Necessity based upon subsequent information obtained. Please review your Certificate wording for details.

A treatment, service, medicine or supply is "Medically Necessary" when it is deemed by us to be necessary and appropriate for the diagnosis or treatment of an Illness or Injury based on generally accepted standards of current medical practice. A service, treatment, medicine or supply will not be considered a Medical Necessity if it is provided or obtained only as a convenience to you or your provider; if it is not necessary or appropriate for your treatment, diagnosis or symptoms; or if it exceeds (in scope, duration or intensity) the level of care which is needed to provide safe, adequate, and appropriate diagnosis or treatment.

Please be advised that precertification is neither an assurance or authorization of coverage, a verification of eligible benefits, or a guaranty of payment, nor is it a denial of such matters. Our consideration and/or approval of your precertification request, as well as all medical claims submitted in connection therewith, remain subject to all Terms of your Certificate, including exclusions for pre-existing conditions and other designated exclusions, benefit limitations, and the requirement that claims be Usual, Reasonable and Customary. Also, the approval of your precertification request should not be considered as the Company's, IMG's or ACM's approval or authorization of, recommendation for, or consent to any diagnosis or proposed course of treatment. Neither the Company, IMG nor ACM has any authority or obligation to select Physicians, Hospitals, or other healthcare providers for you as the Insured Person, or to make any diagnosis or medical treatment decisions on your behalf, and all such decisions must be made solely and exclusively by you and/or your family members or guardians, treating Physicians, and other healthcare providers.

If you and your healthcare providers comply with the precertification requirements of your insurance Certificate, and the treatment, services or supplies are precertified by ACM as Medically Necessary, the Company will reimburse the Insured Person for Eligible Medical Expenses relating thereto subject to all Terms of the Master Policy and the Certificate.

As a utilization review company, ACM has no authority or ability to verify coverages or available benefits, which is the responsibility of you and your providers. If a precertification request is made by telephone, ACM either transferred the caller to or received the caller from the Plan Administrator's Verification of Benefits Department (IMG is the Plan Administrator). However, if a precertification request is received outside normal business hours, the caller will be provided a telephone number to call the next business day to verify coverages and available benefits.

The Plan Administrator will make every attempt to help you and your providers understand the status, scope and extent of available benefits and coverages as outlined in your Certificate. However, no statement made by any employee or representative of the Company, the Plan Administrator or ACM will be deemed or construed as an estoppel or to create any liability against the Company, the Plan Administrator or ACM, or be deemed or construed to bind such entities or to modify, extend or amend the Terms of the Master Policy or the Certificate, unless expressly set forth in writing.

If a definite answer to a specific benefits or coverage question is required for your or your provider's reliance or for any other reason, you or your provider may submit a written request to IMG as the Plan Administrator, including all pertinent medical information and a statement from the attending Physician (if applicable), and a written reply will be sent by IMG on behalf of the Company and kept on file.

If IMG on behalf of the Company elects to verify generally and/or preliminarily to a provider or the Insured Person that a diagnosis, condition or proposed treatment is or may be covered, or that benefits are or may be available as outlined in the insurance Certificate, such verification of benefits does not guaranty either payment or reimbursement of benefits or the amount or eligibility of benefits. Final eligibility determinations, coverage decisions, and actual reimbursement or payment of claims or benefits can only be determined and adjudicated after a proper and complete Proof of Claim is timely submitted, an opportunity for reasonable investigation is provided, requested cooperation is received, and all facts are presented to the Plan Administrator in writing. The Terms of the Master Policy and the Certificate of insurance govern all available coverages, eligibility, and payments made or to be made.

As used herein, the terms Certificate, Company, Eligible Medical Expenses, Hospital, Illness, Injury, Insured Person, Master Policy, Medical Necessity (Medically Necessary), Physician, Plan Administrator, Proof of Claim, Terms, and Usual, Reasonable and Customary shall have the respective meanings and definitions ascribed to them in the applicable policy or certificate wording (available to any insured or provider upon request).

Thank you again for your participation and cooperation in the precertification process. Please feel free to contact us should you have any questions, comments, or concerns.

To comply with pre-certification requirements of this insurance, the insured person or their physician or healthcare provider must perform the following:

1. Contact the company through the plan administrator at the contact information below or on the insured person’s ID car as soon as possible and before treatment or supply is to be obtained.
   • Inside the United States: +1 (800) 628-4664
   • Outside the United States: +1 (317) 655-4500 (collect if necessary)
   • Email: [email protected]
   • Website
2. Comply with the instructions of the company and submit any information or documents required by the company.
3. Notify all physicians, hospitals, and other healthcare providers that this insurance contains pre-certification requirements and ask them to fully cooperate with the company.

©2007 International Medical Group, Inc.
All rights reserved. (Updated 01/07)