Understanding the Pre-Certification Process for Elective Services
What is Precertification of Services?
Precertification for medical services is the process of obtaining approval from an insurance company for the healthcare consumer to have a medical service. If the precertification is not received from the insurance company for the medical service, the insurance company may not pay for the service leaving the healthcare consumer responsible for the entire cost of the medical service. It is important for the healthcare consumer to understand that the insurance company is precertifying the medical service and it is not a guarantee of payment until the billing is received and the medical service meets clinical guidelines.
Services Requiring Precertification
Services that generally require precertification are, Elective Surgical Procedures, MRI’s, CT Scans, Biopsies, Pain Management and other services defined by the healthcare consumers insurance plan. Services requiring precertification can vary from plan to plan. The healthcare consumer should call their insurance to make a service does not require a precertification.
The Precertification Process
The healthcare consumer must rely on their doctor and medical servicing location to coordinate the precertification process. The following is generally how the precertification works and guidance for .specific situations
- The healthcare consumers doctor writes an order for a medical service to be performed and is either give to the consumer or sent to the servicing medical location. In almost all situations, the doctor will send the order. NOTE TO THE CONSUMER: Make sure the order has all the appropriate information; ie, procedure codes, medical necessity documentation, etc.. Ask if the medical service requires a precertification. Lastly, call your insurance company to make sure the precertification is required and it has been processed.
- In some instances, the doctors staff will coordinate scheduling the medical service with the servicing location. NOTE TO CONSUMER: This is acceptable and convenient for the consumer. If the medical service required a precertification, make sure the doctor/medical servicing location has secured it.
- In some instances, the medical servicing location will not perform the medical service without the precertification. This process protects the consumer and medical servicing location. NOTE TO CONSUMER: This may be inconvenient especially if the medical service is urgent. Some insurance plans have an “Urgent Case Clause” for medical services requiring immediate medical care. To expedite, call your insurance plan and doctor’s office.
- Doctors and medical servicing locations may not have secured a precertification and still perform the medical service. Depending on the circumstances, the following could occur:
- Your insurance plan may issue a retro precertification if the consumer, doctor and servicing medical location explain the circumstances to the insurance plan.
- If the servicing location made the mistake, they should assume all financial responsibility. The consumer should not pay for the medical service.
- Medical services may be denied for a variety of different reasons. The consumer should review their Explanation of Benefits to determine the denial reason. NOTE TO CONSUMER: If due to precertification reasons, contact your doctor’s office and have them explain/appeal the claim.
The precertification process can be very confusing for the healthcare consumer to understand and navigate. NOTE TO CONSUMER: Remember, your doctor and the medical servicing location is responsible for securing the precertification for medical service you are receiving. HOLD THEM ACCOUNTABLE!