PRE-NOTIFICATION / 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 seven days before an operation, others two weeks. Some say only 48 hours. 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. Of course pre-certification is not necessary for ordinary visits to your physician. But for major care, MRIs, 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.
For pre-certification, call HCC at:
In the US: 1-800-605-2282
Outside the US: 0-317-262-2132 (collect)
All Hospitalizations, Surgeries, Emergency Evacuations, Emergency Reunions, Trip Interruptions, Repatriation of Remains, Computerized Tomography (CAT Scan), AND Magnetic Resonance Imaging require pre-notification.
Pre-notification may be completed by a phone call from the patient, a friend or family member, or a representative from the medical provider. Pre-notification is a requirement of the policy, but it is does not provide a guarantee that the services will be covered by the insurance.
For medical treatment outside of the US, you may use the provider of your choice without affect on benefits. HCC can offer assistance with locating providers for many areas overseas. If you need assistance finding a physician abroad, please contact our office.
When HCC Medical Insurance Services receives the documentation for your claim, a file will be set up and the claims will be reviewed within 10 business days. If additional information is needed in order to make a benefit determination, the claim representative will begin a written request. Additional information requests may include: medical records, itemized bills, or copy of passport. Once all necessary information has been received and reviewed, the Explanation of Benefits forms and checks are issued within ten business days.