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May 27, 2020

Your Quick-Start Guide to Pre-Certification

By Beth Knight-Pinneo, Alliance Benefits

As hospitals begin to open for non-emergency procedures, now is an excellent time to be reminded of pre-certification requirements. Pre-certification, often referred to as prior authorization, is the process used by health insurance companies to confirm that a service to be performed is medically necessary. Taking time to be sure you have all your ducks in a row before a procedure can help avoid problems and stress down the road.

Typically, your in-network doctor or hospital staff will handle pre-certification. However, it is a good idea to follow up. Any errors or omissions could result in penalties, payment delays, or even claim denials.

What Procedures Require Pre-Certification?

ALL non-emergency facility admissions and surgeries, as well as many other procedures, require pre-certification. If you are an Alliance Health Plan member and have any questions, we recommend calling HealthComp at (800) 442-7247 to confirm what is required for the procedure you are anticipating. They can help you know if there are any further stipulations. For example, if your doctor is opting to perform a more invasive procedure rather than a less invasive one, they will be required to show documentation to explain why this is the preferred method of treatment.

Here are some examples of questions you might ask:

  • Does this procedure require pre-certification?
  • What is the coverage for this procedure?
  • Are there special rules, limitations, or exceptions where this procedure might not be covered?
  • Is this procedure covered only for specific medical diagnoses?
  • Is there a specific plan exclusion for this procedure?
  • Are there any other requirements that are unique to this procedure?

Note: If pre-certification is not required, this does not automatically mean that a procedure is covered, only that the pre-certification process is not required.

It’s helpful to get the name of the person you speak with in case you have questions or concerns later.

What if Your Pre-Certification is Denied?

It’s important to know that in the insurance world, a denial can mean the request can’t be approved based on the information received so far. Sometimes your doctor can provide additional documentation that will reverse the decision.

Keep in mind your provider has hundreds of patients, so you are your own best advocate, and the responsibility is ultimately yours. Be persistent but patient in your follow up calls.

If you’ve received a denial with conflicting information or have questions, you’re welcome to contact Alliance Benefits for help.

Scheduling Your Procedure

  • Be sure to confirm with your provider that the procedure has been approved.
  • It’s important not to box yourself in by scheduling procedures late in the year, too close to travel dates or other important events.

What About Emergencies?

Emergency hospital admissions have other processes called “Concurrent Review” or “Retrospective Review,” where the hospital submits information to the insurance for review while you are admitted or have already undergone the procedure. This review process is to be done within 48 hours of admission. Typically, the hospital will take care of this for you. It’s a high priority for hospitals to do this correctly as they know insurance payment hinges on appropriate information being submitted.

Our Commitment to You

We understand that this process can be complicated and stressful. Alliance Benefits is dedicated to helping you and your family in any way possible. If you have questions or aren’t finding the information you need, please feel free to contact us at (800) 700-2651 or benefits@cmalliance.org.

 

Beth joined Alliance Benefits in January 2001. In her role as Benefits Consultant, she focuses on building relationships with churches and districts, and assisting with health and 403(b) retirement plan questions. She is assigned to serve the churches and districts in the Western and Southern US, and the multi-cultural districts.


Posted in: Health Plan Tools