MANAGING YOUR INSURANCE - PRE-CERTIFICATION APPROVAL

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THE IMPORTANCE OF PRE-CERTIFICATION

Pre-certification means that the insurance company and medical foundation must approve the medical care you are requesting. Sometimes this is called "utilization review." You are given a phone number to verify that the medical treatment you are requesting will be paid for by your insurance. This is how insurance companies make sure that no undue operations or medical procedures take place. By so doing they are able to keep insurance premiums lower for each of us. The real question pre-certification seeks to answer is: Is the care being requested by the client medically necessary?

Companies have different policies as to when pre-certification takes place. Some say you must pre-certify 48 hours before an operation, some say 7 days, and others say 2 weeks. Of course, emergencies are a different matter, but even those must be reported to the company within a specific time limit. Read your policy to determine pre-certification requirements. Pre-certification is not necessary for ordinary visits to your physician. But for major care such as MRIs, CAT scans, x-rays, lab work, in-patient and outpatient surgery, ALWAYS call the pre-certification number on your insurance card. The rule of thumb: If in doubt whether your insurance will cover a medical expense, phone your pre-certification number first and find out.

Also remember that your insurance may not cover what your doctor insists is "medically- necessary" care. For example, a person may have an alcohol problem, and the doctor suggests treatment for substance abuse. The treatment may be "medically necessary," but the insurance policy may exclude coverage for "substance abuse." Carefully read the "Exclusion" page of your policy. Remember the rule: When you are considering any major medical care or expense, always pre-certify.

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