What is precertification?

Also known as prior-authorization or utilization review, is the process of getting preapproval from your health plan before you have any health procedures performed. Precertification for certain procedures help you and your provider know what is covered by your health plan before any services are performed. This is how your plan makes sure medical guidelines are followed.

Why is precertification important?

1)     To determine if a procedure is medically necessary

2)     To avoid unnecessary out of pocket costs by understanding what is covered by your health plan

3)     Will assist in getting the right people involved and can provide you with additional resources

When is precertification necessary?

Plans have varying policies and procedures on precertification. The healthcare landscape is constantly changing, which has created some confusion in the precertification environment. The rule of thumb: If you have any doubts if precertification is required always call the number on your medical card.

What happens if a procedure should have been precertified and is not?

You will be subject to a penalty determined by the plan and illustrated in your summary plan document

What if my condition is an emergency and I don’t have time to precertify?

Emergency situations are allowed additional time without being subject to the penalty.

If my procedure is medically necessary does that mean that the plan will cover that procedure?

No, your plan may not cover what your doctor insists is “medically- necessary” care. For example, a person may have an alcohol problem, and the doctor suggests treatment for substance abuse. The treatment may be “medically necessary,” but your plan may exclude coverage for “substance abuse.” Carefully read the “Exclusion” page of your plan. Again, if you have any questions always call the precertification number on your medical card.