I Need A Precertification. What Is That?

A precertification is a process of confirming medical necessity and collecting information prior to inpatient services and other specialty types of services.  Without a precertification for these services, your health plan may not provide coverage and may deny any claims related to these services.  Some providers may list a precertification procedures list online.  If you are going through a network facility, the facility should automatically do a precertification.  However, that is not always the case.  If a precertification was not done and your claim is denied, often a retro precertification can be submitted.  When these types of services are done, it is up to the doctor to prove that the procedure was medically necessary.  Each carrier has a specific list of criteria that must be met in order to deem a procedure medically necessary.  If you have any questions about a precertification that is needed or your services are being denied, you can always call the number on the back of your ID card to seek help.  As always, our Customer Care Team is here to help as your advocate.

Prescription Prior Authorization- It's Easier Than You Think!

Prior authorization is a requirement for your physician to obtain approval from your health plan to prescribe a specific medication for you. Without this prior approval or authorization, your health plan may not provide coverage, or pay for your medication.  The authorization requirements may vary depending on the carrier. Online drug lists often indicate which medications require prior authorization.  There are some medications that authorizations can be required for due to quantity limitations. If your doctor feels that it is appropriate for you to receive more or less of a medication, they will need to provide the insurance company with documentation. Some insurance plans also have a generic preferred requirement and if your doctor prescribes the brand name only, it may require a prior authorization. Certain medications may require prior authorization depending on the condition that it is being prescribed for. Medications are often approved for treatment of certain conditions; however, if your physician feels that another condition can be treated with a specific drug, they will need to provide the insurance company with that information. There is no guarantee that submitting the information for a prior authorization is going to ensure your insurance company will approve it. If a medication is denied, the insurance company may give suggested preferred alternatives or you, or your doctor can appeal their decision. Again, even with an appeal, there is no guarantee the decision will be overturned. Calling Member Services, the number on the back of your ID card, is the best place to start.  Also our Customer Care Team is available to help as your advocate, if needed.

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