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 Certified Registered Nurse Anesthetist (MD or CRNA)

·         MRI (outpatient only)

·         Scheduled inpatient admission

·         Home Health/Hospice

·         Durable Medical Equipment costing more than $500.00 per item

·         Dialysis

·         Physical Therapy, Occupational Therapy, Speech Therapy (outpatient only)

·         Cancer Care (chemotherapy, radiation therapy, surgical removal, etc.)

·         Sleep Study

·         PET Scan

·         Skilled Nursing Facility admission

·         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 scheduled 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.

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