The procedures that require pre-certification vary with each employer’s health care plan. If you are uncertain about the need to pre-certify, call the Cooperative for verification. As a general rule, you need to pre-certify anytime your doctor has ordered one of the following procedures:
1. Inpatient Hospital Admissions/Skilled Nursing Admissions/Mental Health Admissions (if a benefit)
2. Diagnostic Radiology such as (outpatient only):
Myocardial perfusion Imaging (Nuclear Stress Treadmills)
Cardiac Blood Pool Imaging
3. Durable Medical Equipment such as:
Power Operated Vehicles
Speech Generating Devices
Insulin Infusion Pumps
4. Ear Devices
5. Erectile Dysfunction Implants
6. Gastric Bypass
7. Home & home Infusion Therapy
8. Injectable Medications (Includes IV Infusion)
9. Oral Pharynx Procedures
10. Orthotics & Prosthetics
11. Outpatient procedures—Procedures that could be potentially considered cosmetic. Not all
outpatient procedures require precertification. Please check to make sure.
12. Potential Experimental/Unproven Procedures
13. Sleep Studies
14. Speech Therapy
15. Spinal Procedures
16. Therapeutic Radiology (Radiation Therapy)
18. Procedures with an unlisted CPT Code
· IF IN DOUBT OR YOU HAVE ANY QUESTIONS, PLEASE CALL TO VERIFY IF YOU NEED A PRE-CERTIFICATION OR NOT.
Ask your doctor’s office for the CPT code of the procedure/test/surgery that you will be having. Call the number on the back of your card. You will be asked for basic information such as name, date of birth, id number and group number etc AND THE CPT CODE FOR THE PROCEDURE. DO NOT ASSUME THAT THE DOCTOR’S OFFICE WILL CALL FOR YOU!
The third party administrator will determine if a pre-certification is necessary. If so they will send you to the appropriate UR Company to begin the process. After taking the basic information, the Utilization Management Nurse will need medical information from your doctor to verify that the test/procedure is medically necessary and is being done in the most cost-effective setting.
Once all of the medical information is obtained, it will take 1 working day or less to complete the pre-certification process. In many instances, it takes only a few minutes.
You will receive written notification, via US Mail, that the pre-certification has either been approved or denied. If you have not received that notification at least 2 days before your scheduled test/procedure, you should call the Cooperative.
If a test/procedure is denied, the written notification you receive will include the reason the test/procedure was denied and the procedure for you to use if you want to appeal the decision.
There may be financial penalties for either failure to pre-certify or for having a test/procedure done that has been denied. You will need to check with the employer that provides your insurance or with the TPA that processes the claims. The telephone number for your TPA should be on the back of your insurance card.
You, a family member, or a friend should call the Cooperative as soon as reasonably possible, preferably within 48 hours of a hospital admission.
DO NOT ASSUME THE HOSPITAL WILL DO THIS FOR YOU!
No, doctor's office visits do not require pre-certification, but you may need a referral.