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.

You HAVE The Right To Appeal!

It’s easy to write an appeal…

The option to appeal is a right you have when you disagree how services (claims/prescriptions/benefits) are processed with the carrier.  When you begin to write the appeal there are certain pieces of information you should include to enable the appeal to be reviewed.   

1.    Always have the word "appeal" somewhere in the letter.

2.    Make sure you include the policyholder's insurance information (member ID or social security number, date of birth).  You will also need to include the patient name and date of birth.  See example below:

Policy Holder- John Smith
ID# xxx-xx-xxxx
DOB xx/xx/xxxx
Patient Judy Smith
DOB- xx/xx/xxxx

3.    Make sure to include all dates of service you are appealing in the letter.

4.    Include the reason you are appealing.  (Tell your story/situation)

5.    Include any supporting documentation from your doctor or health professional.

An appeal can take up to 30 days. The explanation of benefits (EOB) gives the information where to send the appeal to. Remember to keep copies of what you send for reference or if you would want to appeal on a higher level with the carrier. Carriers notify in writing directly to the member when the appeal is received and also when the resolution on appeal has been rendered.

The Customer Care Team is available to help with questions on the appeal process.  Please feel free to contact us  Direct  (937-) 260-4300 or toll-free  877-635-5372