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PRE-CERTIFICATION QUESTIONS
and ANSWERS Question:
What do I need to pre-certify? Answer:
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: ·
Scheduled outpatient
procedure requiring use of an anesthesiologist or nurse anesthetist (MD or
CRNA) · MRI (outpatient only) ·
Scheduled inpatient
admission ·
Home Health ·
Durable Medical
Equipment costing more than $200.00 ·
Pregnancy · Physical Therapy, Occupational Therapy, Speech Therapy ·
Cancer Care
(chemotherapy, radiation, surgical removal, etc.) ·
Sleep Study · PET Scan · Skilled Nursing Facilities ·
Other procedures as
directed by your employer Question:
How do I start a pre-certification? Answer:
Simply call the Cooperative. One of the nurses will ask you for some basic
information, i.e., your name, social security number, what test/procedure is
ordered, where it will be done, and the name of the doctor ordering the
test/procedure. DO NOT ASSUME THE
DOCTOR'S OFFICE WILL DO THIS FOR YOU! Question:
What happens when I call the Cooperative to start a pre-certification? Answer:
After taking the basic information, the Cooperative's 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. Question:
How long does it take to complete a pre-certification? Answer:
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. Question:
How will I know when the pre-certification has been completed? Answer:
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 schedule test/procedure, you should
call the Cooperative. Question:
What do I do if pre-certification is denied? Answer:
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. Question:
What happens if I forget to pre-certify or I have a test/procedure done when
it was denied? Answer:
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. Question:
What should I do if I have an unplanned admission to the hospital? Answer:
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! Question:
Do I need pre-certification for an office visit to a doctor? Answer:
No, doctor's office visits do not require pre-certification, but you may need
a referral. |