What is a Pre-Certification?
Pre-Certification is the process by which you can obtain approval for certain non-emergency, medical procedures or treatments prior to the beginning of the proposed medical treatment. This also allows the insurance company to directly pay your medical provider, so you won't have to pay a large amount of money and then claim.
The following services require Pre-Certification:
- Admission to an Extended Care Facility
- Diagnostic Testing
- Therapy (including physiotherapy)
- Surgery requiring general or local anesthesia
- All cancer treatment
- Home Health Care
- Organ Transplants
- Repatriation of Mortal Remains/Burial Services
- Medical Air Evacuation
- Rehabilitation Services
Medical Emergency Authorizations
If you have an emergency, you should go to the nearest hospital or provider for assistance (even if they are not a part of the network). The pre-certification form must be completed and sent to the insurance company within 48 hours of an emergency admission or procedure.
Failure to request Pre-Certification will result in the claim being penalized 30% of covered expenses. This penalty will not count towards out of pocket maximums if any are applicable.
How to perform a Pre-Certification?
To perform a pre-certification you have to download and complete the Pre-Certification Request Form (attached to this article or you can find it in your Online Members Portal) and send it, along with the following documents, to the insurance company at least 5 business days before the scheduled procedure or treatment date:
- Medical Report from your doctor stating the diagnosis, date of occurrence, beginning of symptoms, treatments previously received for the same condition, evolution, complications and current medical/surgical procedures recommended. The medical report must state all the above-mentioned requirements, or you will be asked to complete the missing parts.
- Results of lab tests, X-rays, and all medical tests performed in relation to the specific condition
- A copy of the past medical exams related to this medical condition.
- A copy of the past surgical history related to this medical condition.
- Cost estimate for the services(only outside of the US). This needs to include a complete estimate including the hospital fees, surgeon's fees, anesthesiologist fees and/or assistant fees if one is required
Once the insurance company receives these documents, they will have their medical team review the information and make a decision.If more information is required, you will also be notified.
Once medically approved, the insurance company will then inform you of the approved costs and upload the pre-certification form to your member's profile. They will always try to arrange the payment directly with the provider or hospital. However, the final decision to accept direct payment always lies with hospital or provider.
Pre-Certification in the case of an emergency:
Please note that in the case of an emergency, you should go to the nearest hospital or provider for assistance at once, and contact the company for pre-certification within 48 hours of the emergency admission or procedure.