A utilization management program that requires the insured or the health care provider to notify the insurer prior to a hospitalization or surgical procedure. The notification allows the insurer to authorize payment, as well as to recommend alternate courses of action
A method of providing assurance to the employee or provider that the admission to an institution is a covered benefit. In addition, precertificiation provides information as to the approved length of coverage. Traditionally, this type of review is used for hospital inpatient admissions.
Review processes that verifies the medical necessity and appropriateness of proposed services or supplies.
A process by which approval must be obtained before a planned admission, use of home health services, private duty nursing, hospice services, or home infusion therapy.
the process of obtaining authorization from the health plan for hospital admission or for certain outpatient procedures or tests, e.g. MRI. Failure to obtain precertification often results in a financial penalty or denial of payment for the admission or procedure.
The advance review and approval of proposed hospital stays and specific health care services.
To find out whether treatment (surgery, tests, hospitalization) is covered under a patient's health insurance policy.
A process that evaluates the necessity of certain procedures or recommended treatment plans before the service is performed. To obtain maximum benefits under some plans, precertification must be completed before treatment begins. Also referred to as prior authorization, prior approval or preauthorization.
A requirement that the health care plan must approve, in advance, certain medical procedures. Precertification means the procedure is approved as medically necessary, not approved for payment.
The insurer's approval of an insured's entering a hospital. Many health policies require precertification as part of an effort to control costs.
A review of a proposed hospital or healthcare facility admission or of certain services or procedures prior to receiving them, in order to determine whether the proposed admission or services meets the medical necessity criteria for payment and to receive the maximum benefits available under a WellChoice healthcare plan.
the process by which a medical plan participant seeks advance review of certain types of care and learns what benefits the plan would pay. Some plans require precertification for certain types of care, such as surgeries. Such plans may limit coverage, or even deny benefits, if this precertification is not obtained.
BCBSM’s review of a patient’s symptoms and proposed treatment to determine, in advance, whether they meet nationally recognized clinical screening criteria for inpatient treatment. The process is also used to review selected outpatient procedures, such as MRIs.
The process of notification and approval of elective inpatient admission and identified outpatient services before the service is rendered.
A process used to evaluate the medical necessity of certain care, such as admission to a hospital, therapy treatment, certain medications, surgical procedures and tests.
Notification to a Benefit Plan advising them that you are seeking certain types of medical treatment.
Approval required before either admission to a hospital or for a surgical procedure.
(also known as precert.) It is the process of obtaining authorization, from the insurance company, for certain medical or surgical services. It involves the determination of appropriate medical care. Failure to obtain pre-certification often results in a financial penalty to either the Provider or the Member.
The process of obtaining certification from the health plan for routine hospital stays or outpatient procedures. The process involves reviewing criteria for benefit coverage determination.