RESOURCES

Pre-certification Requirements

Pre-certification ensures that a high level of cost-effective quality care is provided to insureds by evaluating proposed hospital admissions or surgeries before services are provided. A specially trained medical team evaluates both the proposed course of treatment and the patient's specific needs. All evaluations are conducted by healthcare professionals, and are based on national medically accepted guidelines.

When do I need to precertify?  

Pre-certification is needed for any inpatient hospitalization (for any medical services including maternity, transplants, mental illness, mental or nervous disorders, or for alcohol and chemical abuse treatment).

Pre-certification is now required for the following:

·        Skilled nursing facility admissions

·        Home health care services, such as home infusion and in-home physical, occupational or speech therapy

·        Sub-acute medical and rehabilitation inpatient admissions

·        Hospital care services

·        Residential Behavioral Health Services (Mental/Nervous and Chemical & Alcohol)

Pre-certification is no longer required for any outpatient surgery. You or your physician must call the pre-certification number on your ID card prior to admission to obtain pre-certification.