Precertification and Health Insurance: What to Check Before Care
Know when precertification is required, who submits the request and why approval does not guarantee payment for a planned medical service.
2 min readBy Dustin Neider
Key Takeaways
- Approval is not a guarantee of payment.
- Confirm service codes, dates, provider and facility.
- Keep the written decision and appeal instructions.
Precertification, also called preauthorization or prior authorization, is a health plan review of whether a proposed service is medically necessary. U.S. group plans may require it before certain non-emergency treatment, drugs or equipment. Approval does not guarantee payment: eligibility, covered benefits, network rules and cost-sharing still apply. Confirm the requirement and written decision before planned care.
When is precertification needed?
Check the plan's current requirements for the exact procedure, drug, facility and service date. The provider typically submits clinical records, but confirm responsibility with both the provider and plan. A referral, cost estimate and authorization are different documents. HealthCare.gov defines preauthorization and states that it is not a payment promise.
What should you confirm before treatment?
Before planned treatment, confirm that the written authorization matches the actual service, provider, facility and dates, and that enrollment and network requirements remain satisfied. Ask the plan about separate professional or facility reviews and your expected cost-sharing. Keep the approval reference, but remember that authorization alone does not establish final claim payment.
- The service code and diagnosis information submitted by the clinician.
- The approved provider, facility, date range and number of visits.
- Whether both professional and facility services need review.
- Your enrollment, network status, deductible and estimated cost-sharing.
Record the authorization number and retain the written approval. If the treatment plan changes, ask whether another review is needed. Do not delay emergency care to seek routine precertification; emergency rules differ.
What if the request is denied?
Ask for the written reason and applicable criteria. A provider may correct missing records, request a clinical discussion or support an appeal. Use the plan's appeal process and ask about expedited review if waiting could seriously harm your health. HealthCare.gov explains appeals and external review; the plan type determines the specific process.
A predetermination review can help estimate benefits but does not replace required authorization. Employers should tell employees where to obtain help without collecting unnecessary clinical details or promising that the broker can overturn a medical decision.
Authorization workflow and tracking sheet
Use current plan documents and the plan's written instructions, not a generic approval checklist alone. Do not delay emergency care for routine authorization.
| Responsible party / step | Records and next action |
|---|---|
| Confirm requirement | Member/provider checks the specific service, drug or equipment against current requirements; record the plan contact and date. |
| Assign submission | Provider confirms who sends clinical records, which channel to use and whether facility and professional reviews are separate. |
| Track receipt | Keep submission date, request reference, missing information and the party responsible for sending it; ask the plan for its applicable review timeframe. |
| Read decision | Member/provider checks approved codes, provider, facility, visits, dates and remaining conditions against the proposed care. |
| Resolve denial or change | Get written reasons and appeal instructions; ask about expedited review where appropriate. Changed treatment may need another request. |
| Employer handoff | HR/broker supplies secure contacts and authorized administrative follow-up, not clinical decisions. Track deadlines without collecting unnecessary medical records. |
Clarify agent-of-record claims and administrative support responsibilities before asking a broker to assist. Plan decisions and appeal rights remain governed by the plan and applicable rules.
General information, not legal, tax, or medical advice; plan documents and current rules control.
For employer plan support, request a group health insurance quote.
Frequently Asked Questions
Is precertification the same as a referral?
A referral directs a patient to another clinician; precertification is a health plan’s review of a proposed service. A plan may require both a referral and precertification, so confirm the requirements before nonemergency care.
Can an approved service still leave me with a bill?
Precertification approval does not guarantee that a service will be paid in full. Deductibles, coinsurance, exclusions, eligibility and network rules can still affect the health plan’s payment and the member’s bill.
About the author
Dustin Neider — President of PCIS, insurance broker and ACA specialist with nearly 20 years of experience in health insurance.
