ABOUT THIS EDITION
Dear Insured Member,
We are delighted to present the July edition of the bimonthly UNSMIS newsletter!
In this issue we will discuss the following:
- Medical Adviser and Prior Authorization
- Hospitalization
- Emergency Hospitalization
The newsletter will be sent to insured members via email, will be published on the website and will appear as a pop-up window on the eClaims Portal.
We hope you find this newsletter helpful.
Kind regards,
The UNSMIS Team
|
|
|
MEDICAL ADVISER AND PRIOR AUTHORIZATION
|
|
|
The Medical Adviser is a doctor who reviews your medical documents, quotes, and other relevant documentation to assess a given treatment you wish to undergo, particularly regarding its efficiency, duration and cost.
Prior to any medical treatment, surgery or purchase that, pursuant to our Internal Rules, is subject to prior authorization, it is essential to send us all relevant documentation (a prescription or referral, medical report, quotation, medical imagery, etc.) at least two weeks in advance.
In the USA, all elective surgeries are subject to prior authorization. (Rule VIII, paragraph 4(f) of UNSMIS’s Internal Rules)
If any of the above is applicable in your case, the request for prior authorization must be sent to our Medical Adviser at medrepunsmis@un.org.
Any lack of documentation risks delaying the final decision; therefore, it is essential to send all available, relevant documents to the Medical Adviser and for these to be clear and detailed.
|
|
|
In general, approvals are granted for the duration of the medical prescription (for a maximum duration of one year). In some cases, the Medical Adviser wishes to assess the effectiveness of a given treatment. In such cases, it is possible that the Medical Adviser approves treatment for a shorter period than the one suggested by the treating physician.
When submitting your claim, it is important to attach the approval of the Medical Adviser, as well as all supporting documentation. Regardless of the duration of the prior authorization’s validity, it is essential to ensure that your prescription is still valid. Should your prescription expire while the prior authorization is still valid, a new prescription must be issued.
Failure to obtain a prior authorization can result in part or all the medical expenses not being reimbursed. Proceeding with a treatment following an initial limitation/denial by the Medical Adviser can result in part or all the medical expenses not being reimbursed.
|
|
|
Similarly, if a treatment is approved but limited to reasonable and customary limits by the Medical Adviser, all costs in excess of the authorized amount will not be reimbursed.
If your treatment must be extended beyond the approved term, a new request is to be submitted. Please send an updated prescription or medical report, along with any supporting documents, enabling the Medical Adviser to review your case.
|
|
Hospitalization in an approved medical establishment (in accordance with Rules VIII.4 and VIII.8 of the Internal Rules) encompasses inpatient care provided by the staff of the establishment and other standard services offered by the facility.
Ambulatory treatments or minor day procedures performed in a hospital are not considered hospitalization cases.
The reimbursement rate of hospitalization depends on the type of room that you stay in:
- The cost of hospitalization in a public ward of a public establishment is reimbursed at a 100% rate.
- In most other cases, the cost of hospitalization is reimbursed at a 90% rate. This applies to stays in a two-bed or semi-private room.
- The private room supplement is not reimbursable by UNSMIS.
- Hospitalization in an establishment not providing semi-private care and only offering private rooms, approved by the competent health authorities of the country concerned, is reimbursed at the 90% rate, but the room portion will be limited to 75%.
- If the invoice does not clearly identify the cost of the private room, a standard rate of 20% of the total invoice amount will be used to approximate the cost of the room.
|
|
|
If the medical establishment only uses package price invoicing (i.e. a fixed lump sum for everything), room costs will be considered 20% of the total invoiced amount and reimbursed at the applicable room rate. The remaining 80% of the total billed amount—including all examinations, treatments, and medications—is reimbursed at 90%.
If your hospitalization extends to a period longer than 30 days, it is essential to request the prior authorization of the Medical Adviser for continued entitlement to coverage by UNSMIS.
If you decide or need to obtain medical care (e.g., hospitalization, surgery) away from the duty station or the place of residence, at a place where medical costs are higher than in Geneva, reimbursement shall not exceed the usual, customary and reasonable pricing of the given treatment in the country where it is performed, or the cost of equivalent treatment provided in the Canton of Geneva.
|
|
|
|
Please be reminded that in case you seek treatment in the United States of America, special rules will be applied based on Rule VIII/ 4 (f):
“For insured members whose duty station (for staff members) or legal place of residence (for other insured members) is not within the United States of America , the following rules apply to medical treatments received in the USA: (i) Treatments listed under benefits 2, 3, 5, 13, 16, 24 and 25 of the table in Annex III are subject to Prior Authorization from the UNSMIS Medical Adviser, unless these are received due to a Medical Emergency and/ or an accident as defined under Rule II of the Internal Rules. This is in addition to treatments requiring Prior Authorization as listed in table in Annex III.”
|
|
|
EMERGENCY HOSPITALIZATION
|
|
|
|
A medical emergency is defined as “an unanticipated, acute medical condition that necessitates immediate medical intervention due to the risk of severe health deterioration or threat to life if treatment is delayed. Medical emergency is characterized by the inability to postpone treatment due to the severity of the condition which requires the admission to hospital for emergency care within 72 hours.”
To ensure you receive prompt assistance during urgent medical situations, we have introduced a new emergency helpline number:
+1 800 340 1395 (toll-free if called from the United States)
or +33 1 55 62 53 46 (standard rates apply).
Our Emergency Helpline is dedicated to providing immediate hospital admission assistance for members and their dependents facing critical medical emergencies. This service is exclusively available for situations that fit the definition of an emergency.
|
|
|
In the event of an emergency, please follow these steps:
- If immediate medical assistance is needed, always call the local emergency number first to arrange ambulance transport if necessary.
- Once you can, please call our new helpline at +1 800 340 1395 or +33 1 55 62 53 46.
- You will be connected to a globally recognized assistance company that will verify your UNSMIS coverage and assess the emergency nature of the situation.
- Provide your name, insurance ID, insurer (UNSMIS), location, and details of the event.
If the hospital accepts our guarantee of payment or is part of our network, UNSMIS will directly cover the costs of a public ward or a semi-private room. The member’s out of pocket share of the expenses will be recovered afterward.
Emergency hospitalizations are reimbursed according to the same rates as standard hospital stays. In the event of emergency hospitalization, no prior authorization is required.
|
|
|
Important reminders:
- In life-threatening situations, always call the local emergency number first to arrange ambulance transport if needed.
- This 24/7 emergency number is solely for emergency hospital admissions.
- This is not a Medevac number. All Medevacs must be approved in line with established procedures and obtain necessary clearance from the Organization you are working for.
- A physical insurance card is not required. If asked for your card, the e-card available in the UNSMIS mobile app will suffice.
|
|
|
|
|
