Precertification for health care services is a requirement for countless plans. As the patient, you are responsible for understanding your policy, but that doesn’t mean that you do.
Para ayudarlo a comprender mejor su plan, cuáles son sus opciones y cómo evitar sanciones por no obtener una autorización previa para sus servicios de atención médica, creamos una descripción general completa de esta cláusula. Sin importar dónde obtenga un seguro médico en Texas, lo alentamos a que comprenda su cobertura. Hacerlo puede ahorrarle miles de dólares.
Esto es lo que necesita saber sobre la precertificación y cómo afecta su inversión en atención médica.
¿Qué es la precertificación?
If your plan has a preauthorization or precertification clause, you’re required by them to get approval for certain medical services. Even if your doctor has already approved of treatment in her office, you must get approval from your insurance provider. Also known as “prior authorization” or “preapproval,” (we’re using these three terms interchangeably in this post) this process isn’t as painful as it might seem. Many of the top Houston health insurance plans require this certification on common medical procedures.
En definitiva, la autorización previa tiene que ver con la cobertura del seguro. Como paciente, debe asegurarse de que está cubierto para un procedimiento médico específico o determinar si es necesario un medicamento recetado antes de seguir adelante con el tratamiento. Algunas compañías de seguros médicos también exigen que cumpla con ciertos criterios antes de brindar cobertura para el tratamiento o los medicamentos que le recomendó su médico.
Insurance companies reserve the right to change their policy terms without notifying you, which is why they often require this process on their plans. While this isn’t the case for every insurance plan, it is important that you are aware of what your plan states and whether or not a preauthorization is required. One way to find out is to read through your entire insurance policy. An easier way is to simply contact your provider and ask them.
Failure to adhere to your insurance policy’s requirements can cost you thousands of dollars out-of-pocket, but with pre-authorization, you can save money and avoid penalties from your insurance provider.
¿Cuando es necesario?
Not every health care treatment requires pre-approval. Basic health care performed by your primary health care practitioner like checkups etc. doesn’t typically require approval from your provider. However, specialized services do require it.
Coverage plans will outline which services require preauthorization, but it’s important to have a basic understanding of what those might be. Having a Primary Care Insurance Solutions consultant in your corner eliminates any confusion surrounding your coverage, but most of the services that require pre-certification include:
- Home Care Services—Skilled nurses, hospice, therapy etc.
- Surgical Procedures—Nearly all surgeries must have the approval of your insurance provider.
- Non-life-threatening Ambulance Service—If your life isn’t in immediate danger, you may have to get pre-approval from your insurance company before using this service.
- Radiology examinations—X-Rays, MRI’s, CT Scans, and Ultrasounds.
- Services for Pain Management—Trigger Point Injections, Discogram, Joint Injections, and Facet Joint Injection
- Mental health therapies—Experimental therapies, drugs etc.
- Inpatient Facilities—Post-Acute Facilities
- Laboratory Services—Out-of-network laboratory services most often require pre-authorization.
- Specialized Pharmaceutical Drugs—Depending on the drug, prior authorization is required. Contact your insurance provider for more detailed information.
- Extensive Occupational Therapies—Many plans cover the initial visit without pre-approval, but after that first visit you may be required to get certification for their use.
- Vision Services—Depending on your plan, eye care may require prior authorization.
¿Por qué obtener una preaprobación?
If you decide to go ahead with a treatment that requires your insurance provider’s preapproval you could end up paying full costs for the services. Even services that are clearly covered in your plan won’t be covered if your insurance company requests precertification. If you have surgery, for example, and fail to get authorization you could be left with a bill for tens of thousands of dollars with no help from your insurance company.
¿Cómo obtener la autorización?
Once you have your list of covered healthcare services in hand, the next step is to figure out how to get authorization for the services that aren’t automatically covered.
Sí, es posible que su médico ya haya aprobado el servicio o el medicamento que le recomendó, pero su compañía de seguros médicos debe verificar que la atención sea absolutamente necesaria. Lo hacen por dos razones: 1. Para protegerlo de recibir un tratamiento médico innecesario y 2. Para ahorrar costos.
You may not need an elective specialized therapy, for example, but your doctor may have recommended it. Your insurance company may disagree with your doctor’s recommendation. Because of this, your provider requires you request that pre-certification.
Una vez que su médico le recomiende un tratamiento que requiere autorización previa, el siguiente paso es que se comunique con su proveedor de seguros.
For expensive prescription medications, your doctor must clearly explain that the drugs are medically necessary for your health. Immediately notify your doctor’s office if you discover their prescribed medication requires pre-approval.
Para tratamientos médicos como procedimientos ambulatorios o con hospitalización, su médico deberá comunicarse nuevamente con su compañía de seguros para explicarle el motivo por el cual le ha recomendado el procedimiento y por qué es la única manera de garantizar su salud.
If you’re considering going out-of-network, contact your provider and explain why you plan to do so. While they may not offer full coverage for any out-of-network treatments, they may partially cover the costs. Call before seeing any out-of-network provider to be sure.
What to Do If You Don’t Get Approval
Cuando se le niega la cobertura de servicios de atención médica o medicamentos recetados costosos, deberá pagar la totalidad del servicio o medicamento. Sin embargo, tiene derecho a apelar la decisión tomada por su proveedor de atención médica. Sus documentos de beneficios tendrán un proceso paso a paso sobre cómo apelar esas decisiones.
Alternatively, if your doctor provides a prescription that your health care insurance company rejects they may recommend generic medications or a different medicine they believe will work just as well. This saves your provider money and reduces any headache on your part. If you find that the medication doesn’t work as well, you can again appeal their decision.
If these tips don’t work, you can always contact our team.
ES 
EN