IQVIA Benefits Handbook
HOSPITAL/FACILITY SERVICES
Inpatient Hospital Services
The plan provides coverage when you are admitted to a hospital as an inpatient. If you are admitted before the effective date of coverage, benefits will not be available for services received prior to the effective date. If you are in the hospital as an inpatient at the time you begin a new benefit period, you may have to meet a new deductible for covered services from doctors or other professional providers. You should work with your doctor to make sure pre-certification has been requested. Pre-certification must be obtained in advance from Aetna or Kaiser or your benefits may be reduced or denied.
Covered services include:
  • Medical care provided by a doctor or other professional provider.
  • Room and board at the hospital's current rate for a semi-private room. Private rooms are paid up to the cost of a semi-private room.
  • Use of the operating room, delivery room, recovery room, nursery and related services.
  • General nursing care.
  • Special care units (e.g., intensive care or critical care) at the plan's negotiated rate for in-network care and the daily room rate for out-of-network care.
  • Drugs administered by the hospital.
  • Diagnostic services and medical supplies.
  • Use of appliances and equipment ordinarily provided by the hospital.
  • Short-term rehabilitative therapies and other therapies.
Outpatient Services
Benefits are provided for outpatient services received in a hospital, a hospital-based facility or an outpatient clinic.
Covered services include:
  • Medical care provided by a doctor or other professional provider.
  • General nursing care.
  • Drugs administered by the facility.
  • Diagnostic services.
  • Medical supplies.
  • Use of appliances and equipment ordinarily provided by the facility for the care and treatment of outpatients.
  • Operating room, observation room, recovery room and related services (outpatient surgery).
  • Short-term rehabilitative therapies and other therapies.
Multiple Surgical Reduction
Multiple surgeries performed during one operating session result in payment reduction of 50% to the surgery of lesser charge. The most expensive procedure is paid as any other surgery.
Other Health Care Facilities
The plan provides benefits for covered services received in other health care facilities including a skilled nursing facility, rehabilitation hospital or sub-acute facility for medical care and treatment. You should work with your doctor to make sure pre-certification has been requested. Pre-certification must be obtained in advance from Aetna or Kaiser or your benefits may be reduced or denied. Skilled nursing facility services are limited to a combined in-network and out-of-network maximum of 120 days per calendar year. Except for any day of confinement, covered expenses exclude charges that exceed the daily limit.