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Precertification Guidelines

Most of the time, groups utilizing the HealthSpan provider networks must also use HealthSpan’s care management which can include all or some of the services listed below:

  • Utilization Review
  • Case Management
  • Health Coaching
  • Disease Management (Help with Chronic Conditions)
  • Health Risk Assessments
  • Wellness Programs (Healthy Living)
  • Predictive Modeling

Utilization Review includes Precertification or Prior Authorization. The purpose of Precertification is to establish medical necessity prior to services being rendered. In some cases, Precertification is needed to establish whether services can be rendered at a given location or provider type based on the terms of the plan.

An approval of medical necessity is not a guarantee of eligibility or benefit coverage. Providers should always contact the administrator or insurer on the member’s ID Card to determine if a service request is a covered benefit for the member.

Services requiring precertification vary by plan. HealthSpan makes annual recommendations to plan sponsors. Click here to review our standard precertification list for 2013. You can use the Provider Login to look up whether the member’s group uses our standard list or an alternative. Please be sure to call to ensure you meet the provisions of each plan as changes may occur at any time.