Medical Policies & Precertification Guidelines
HealthSpan only reviews health service request (such as requests for hospitalization, physical therapy, etc.) information for the purposes of determining medical necessity. Approvals of medical necessity ARE NOT GUARANTEES OF ELIGIBILITY OR BENEFIT COVERAGE. You should always contact you Plan Administrator to determine if a service request is a covered benefit under your health plan.
The following is information about specific areas of health service request review
Who is Responsible for Pre-Certifying a Service?
Please check your Member ID card to determine if HealthSpan is the company responsible for providing your pre-certification and other medical management services. If this is still not clear to you, contact your human resources office or plan administrator/Third Party Administrator (TPA) to determine who is responsible for pre-certifications and how to contact them.
When HealthSpan is responsible for providing your pre-certification and/or other medical management services the below provides general guidelines to help you through the pre-certification process. Specific services requiring pre-certification under your health plan are determined by your employer. Please consult your plan documents or contact your plan administrator/TPA or HealthSpan for specific services that require pre-certification.
What Does Pre-Certification Mean?
When your plan requires pre-certification of a service, they are requiring you to have the service reviewed prior to it being delivered to you. This review requires you or your provider to give specific information to HealthSpan about the services requested. While it is often your provider who submits the information and obtains pre-certification, the member is responsible to insure this is done.
Determining Medical Necessity
When HealthSpan is responsible for the pre-certification process, HealthSpan determines if the service being requested is "medically necessary". "Medical Necessity" is generally defined by your specific health plan. In addition there may be service specific definitions (examples: Obesity Surgery, Speech Therapy) of Medical Necessity defined by your health plan.
A common description of Medical Necessity is: medical necessity (or medically necessary): services, procedures, and supplies that:
- are consistent with the symptom or the diagnosis and the treatment of an illness or injury,
- are required for the prevention, diagnosis, cure, or treatment of a health-related condition, including services necessary to prevent a detrimental change in either medical or mental health status,
- are provided in accordance with generally accepted medical practice and professionally recognized standards,
- provide care safely given at the appropriate level of service,
- are not experimental services, cosmetic services, maintenance care, or custodial care, and
- are not provided solely for the convenience of the Plan participant or the provider.
In determining questions of medical necessity
, consideration is given to the customary practices of providers
in the community where the service is provided. However, the fact that a provider
may prescribe, order, recommend, or approve a service or supply does not, of itself, make that service or supply medically necessary
The Pre-Certification Process
At the time of the pre-certification request, HealthSpan will provide a reference or "referral number. This number is used to identify the request in any future conversations. Often HealthSpan can make a decision on Medical Necessity at the time of the initial request. If this occurs the individual making the request will be notified of this approval. If the request requires additional review by a nurse or physician the person requesting will be notified of this along with any other information that might be needed from the provider in order to complete the review. Once the information is received the review is usually completed within two business days. Once a determination (decision) is made on whether or not the services requested are medically necessary, that will be communicated by HealthSpan to the provider and your Plan Administrator.
What Happens if My Request is Denied?
If the services are found to not be medically necessary, they will be denied. HealthSpan will notify your provider who is able to provide additional information and request reconsideration from HealthSpan. This is not an Appeal (see below) as defined by your health plan but is often the first option you and your provider have to obtain a second review of the request. This request is reviewed by the same HealthSpan physician who made the initial determination. Any change in the decision by this physician will be dependent on your provider submitting additional or new information that supports the medical necessity of the request.
You will also be notified in writing by your plan administrator of a denial decision and your rights to Appeal this decision. You may ask your physician to have this request reconsidered first, but ultimately it is your right and responsibility to submit a formal appeal. In most cases appeals must follow a specific format and be sent to a specific department or person as defined by your Plan Administrator. Be sure to contact your Plan Administrator, not HealthSpan, if you wish to file an appeal.