Wednesday, March 14, 2012


In some cases the insurances require the provider to obtain permission prior to performing a procedure. This is called precertification, preauthorization, prior authorization, and precert or preauth for short. Precertification is required by some insurance companied prior to inpatient admission, some out patient procedures and tests. You should check with the insurance when in doubt about a procedure’s requirements for precertification and keep a master list of what does and does not require authorization for future reference. Update the list frequently and watch insurance updates for changes.

So here’s how it works. As noted in the eligibility post, check with the insurance during an eligibility check to see what type of procedures require authorization. The insurance representative will not give you a full detailed list of every procedure, but the information they provide will act as a guide. A good rule of thumb is that HMO plans often have strict precertification regulations whereas PPO plans are more lenient and traditional Medicare never requires authorization or referrals at all. Remember that Medicare patients may choose a Medicare HMO, which is a Medicare replacement not Medicare. Medicare HMOs will follow HMO rules.  

Here’s how the process works: The doctor will tell the staff to schedule a procedure for a patient. The medical office professional knows that means that they must contact the insurance company’s precertification department and request the authorization before the procedure date. There are three ways of obtaining precertification; the method you choose will depend on the insurance’s requirements.

The first way is by phone. To do this, call the insurance, provide the necessary information about the patient’s condition and the planned treatment, your request will be reviewed and an authorization is generated. Alternatively the insurance may require/allow authorization via fax or electronically. Insurances that require a faxed request submission often have specific forms that they will provide for your submission. Complete the form accurately and fax it to the insurance company. If your fax machine is able to provide confirmation of a successful transmission, you should print that and keep it. Documentation is important if the insurance claims that the request was not received in time. Some insurance companies are now accepting electronic precertification requests through their web sites. Any web-site transactions with insurance require pre-registration, but the registration time will save you a ton of time in the end.

Precertification can take time depending on many circumstances, such as the insurance’s requirements and patient’s diagnosis. Be sure to precertify the procedure as much in advance as possible to avoid any problems. Keep a log of the amount of time that precert takes listed by insurance carrier and record the insurance’s preferred method (phone, web-site or fax), insurance contact information and the usual procedures that require authorization so that you can be prepared in the future.  If you are not sure if a procedure requires authorization, call the insurance. It is better to err on the side of caution than to run the risk of the claim denying for no prior authorization.

If a procedure is not precertified in advance of the procedure date, the claim will be denied. Very few insurance carriers will allow a retroactive (after the procedure) authorization and if they will most reduce the payment amount since you did not adhere to their guidelines. 

To follow is a list of the information that you will need to have ready to precertify a procedure.

  • Doctor’s name
  • Practice name
  • Provider  and group NPI numbers and tax id
  • Patient name
  • Patient date of birth
  • Patient’s insurance identification number
  • Procedure to be preformed
  • Date of the procedure
  • Both primary and supporting diagnosis
  • Symptoms, clinical indications or descriptions such as size or location
  • Facility or location where the procedure will be preformed
  • Supporting documentation (office notes)
  • The patient’s chart. Since insurance requirements vary, it is best to have the chart available to refer to for questions.
Most insurance companies have dedicated precertification departments. The department is usually staffed with both clinical and non-clinical members and directed by a physician. When you call you will speak with a person who will take the information about the precert and review the insurance rules as they apply to this situation. In some cases, you may be told that the procedure doesn’t require precertification, the request may be immediately approved (depending on the diagnosis, procedure and insurance company) and in other instances the request will be reviewed by the clinical staff or even the physician medical director.

You must understand, a procedure is not authorized until the insurance representative gives you the authorization number. If they collect the information and say that they will call you back after medical, clinical review the procedure is not authorized until they call back. Many times in the case of an expected call back, the representative will give you a reference number, this is not a precertification number just a request tracking number. When in doubt ask the insurance representative for clarification. Again, if a procedure requires authorization and authorization is not obtained prior to the services being rendered, the procedure will not pay!

  • Important to remember precertification rules:
  • Make sure that you have all of the required information before you call.
  • Get the insurance representatives first name and last initial (at least).
  • Always insist that precertification requests be checked with the CPT code NOT the name of the procedure as there can be errors with the name alone.
  • Be prepared to provide clinical information like symptoms, locations, size and severity.
  • Have chart notes ready for submission to the insurance for review.
  • Listen to the representative carefully and take notes on what they are saying about the insurance requirements.
  • Know the difference between a reference number (for tracking you request) and a precertification number (approving your request).

You should keep eligibility and precertification information either electronically or in the patient’s paper chart. If you choose to store it in a paper format, make up a form to be completed so that your inquiry and information is consistent. To follow is a link to examples of forms that will help to maintain the information from the eligibility or precertification calls. Eligibility and precertification Forms


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