Similar to pre-admission certificate, a condition of receiving health benefits. Review and approval process that must be completed before services are provided, when an inpatient or ambulatory site is proposed for care. The review process may include an assessment of the physician's proposed protocol and fees. Compliance with changes in the proposed treatment plan recommended by reviewing entity may be a condition of receiving full coverage under the health benefit.
A requirement by an insurance company or health plan that certain services must be approved in advance to be covered or to be covered without a penalty.
written acknowledgement by a health plan that the specific drug requested by a provider is medically necessary, thus providing a promise of reimbursement once that drug is administered or dispensed.
this is another term for pre-certification which is the process of obtaining approval for a service or medication. Without this, the service or medication is not covered.
The approval process that determines if a services is medically necessary for your condition. The process also includes referring you to an appropriate provider for your condition.
A managed care rule that limits or denies payment for services if they are not reviewed and authorized as being medically necessary.
A statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract.
Pre-authorization is a review of all pertinent medical information to determine medical coverage for certain medical services. A memberâ€(tm)s physician/provider can obtain pre-authorization from the health planâ€(tm)s Medical Care Management department 7-10 days prior to the services rendered. The following medical services require pre-authorization: Any hospital admission Any inpatient or outpatient surgery Skilled nursing facility admission Obstetrical admission Outpatient diagnostic tests Rental or purchase of durable medical equipment / prosthetics Home Health care / hospice Rehabilitation services: cardiac, pulmonary and vascular Therapy services: physical, occupational, speech Certification of medical necessity is not a guarantee of medical payment. Benefits are always paid according to the memberâ€(tm)s eligibility and the provisions of the health plan. Failure to obtain pre-authorization may result in a penalty of up to $500. Plan members may view authorizations online at My Optima.
Previous approval required for a referral to a specialist or non-emergency health care services.
The insurance carrier authorizes medical treatment, dental treatment or hospitalization prior to the services being performed. Hospitalization out-of-network requires pre-authorization. Medical pre-authorization may be obtained by calling 1-877-323-9930. Dental pre-authorization may be obtained by calling 405-607-2100 or 1-800-522-0188.
A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided.
Permission granted by insurance company for certain services to be covered. This request is made by your doctor in most cases before services are rendered. Review your policy to see if this applies to you.
Also called "pre-approval." An approval that a managed care plan member must ask for from the plan or primary care doctor fin order to know that the plan will pay for certain medical services, such as an inpatient hospital stay. In some plans, of you do not get pre-authorization the plan will not cover the care.
If a feature of your policy, an inpatient or outpatient surgery or procedure may need to be authorized by the insurance company in advance.
The prior approval needed from the health plan for planned elective admissions, durable medical equipment and certain prescription drugs. In some contracts, it is the member's responsibility to obtain pre-authorization. Be sure to check your Evidence of Coverage or Group Certificate and any associated riders and endorsements for more details.
An insurance plan requirement in which you or your primary care physician needs to notify your insurance company in advance about certain medical procedures (like out-patient surgery) in order for those procedures to be considered a covered expense.
An approval from the particular authority (usually insurance company in dentistry) before any action (treatment) is carried out.
The approval that you must obtain from your insurance provider prior to treatment for non-emergency care. This is not required for the student health insurance plan.
The process of getting permission from your insurance organization for certain services before they are provided so that the services can be considered eligible expenses. Usually required for hospital and outpatient services.
This requirement of some health care programs means that a review and approval process must be completed before services, or medications are provided.
The prior approval required by some payers before benefit payments will be granted.
A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization or surgery and receive authorization for the service.
Certification performed prior to scheduled, elective, or urgent health care. This process screens for medical necessity and/or appropriateness of inpatient versus outpatient treatment. Prior approval for the medical care of a diagnosed injury or sickness. Determination is made by the insurance company or designated organization and is based upon whether treatment is consistent with currently accepted medical practice.
A non-posted pre-approval for a future transaction, followed, within a specific time interval, by the actual financial transaction posted against the Cardholder's account. Pre authorizations are used primarily in P. O. S. situations where the Cardholder wishes to obtain "advance approval" or "verification" that sufficient funds are available to make a subsequent purchase using a debit card.
Approval that insureds must receive from the insurance company in advance of receiving certain services, such as inpatient hospital admissions (non-emergency), non-emergency outpatient hospital services, and ambulatory (outpatient) surgery services.