Precertification, or Prior Authorization, describes a review to determine the Medical Necessity of health services requested by a doctor, other provider or the member before those services are performed. A review for Medical Necessity assures that the service is in line with normal treatments for the health issue, is not experimental and meets other standards. It is also an opportunity for you or your provider to learn about other treatments and options.
Receiving approval for medical necessity IS NOT A GUARANTEE OF ELIGIBILITY OR BENEFITS.
Coverage under the health plan is determined when a claim is processed. Claims processing addresses what is actually billed by the provider and whether the patient is eligible and covered by the plan on the day of service.
To confirm that a planned healthcare service and the patient receiving it are covered by the plan, contact your plan administrator, insurer or Third Party Administrator. See the Member ID Card for the number to call.