Pre Authorization Determination
What is PreAuthorization & Pre Certification?
While providing the treatment to patients, providers need to perform some services they cannot perform without letting the patient’s insurance company know about the treatment plan and get approvals from them of such services in advance. The growth of medical aid organizations as the first paid healthcare provider has introduced prior authorization and pre-certification ideas for the language of the health insurance language. The purpose of both practices is to reduce unnecessary costs by forcing the payer to agree that the service is medically necessary before the payment is made. We have a trained team of authorization agents for technical and non-technical authorization and certification processing.
Difference between Pre Authorization & Pre Certification
Pre-authorization
A pre-authorization requirement means the insurance company will not pay for a service unless the provider (a physician or hospital) gets permission to provide the service. Sometimes, this permission is to ensure that a patient has benefit dollars remaining (e.g., a payer may limit a patient to 12 chiropractor visits in a calendar year), other times it is to ensure that a particular kind of service is eligible for payment under the patient’s contract. Authorization can be granted retroactively. For example, a patient or hospital may have a 24-hour window to notify a payer after receiving emergency care.
Pre-Certification
A pre-certification requirement means a payer must review the medical necessity of a proposed service and provide a certification number before a claim is sent to be paid. This is often true with elective surgeries. A physician or nurse with the payer must review a physician’s order and the medical record to agree that a proposed procedure is medically appropriate.
Pre-Determination
Pre-Determination is a review by the medical staff of the insurer’s health plan, deciding whether they agree the treatment is appropriate for your health needs. Pre-Determination is done before starting treatment, so you know early if the health insurance plan will reimburse it or not.
Approval process
In general, a provider will contact the payer to obtain the necessary approvals. This is transmitted in the form of an authorization or certification number which is attached to a claim. Usually, the patient is not involved in the process.
Denial of coverage
If the provider fails to obtain the necessary financial clearance before providing services, then the payer can deny some or all of the authorization requests. The provider usually has the right, within a contract with the payer or under state insurance law, to appeal the denial through several levels including an administrative law judge.
