Everything You Need to Know About Precertification & Health Insurance

A group of people discussing everything you need to know about pre-certification and health insurance at a table in a meeting.

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.

To help you better understand your plan, what your options are, and how to avoid penalties for failing to get preauthorization for your health care services, we created a complete overview of this clause. No matter where you get Texas health insurance, we encourage you to understand your coverage. Doing so can save you thousands of dollars.

Here is what you need to know about precertification and how it affects your investment in health care.

What is Precertification?

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.

Ultimately, preauthorization is all about insurance coverage. As the patient, you should make sure you are covered for a specific medical procedure or determine if a prescription drug as is necessary before you move forward with treatment. Some health insurance companies also require you meet a set criteria before they provide coverage for the treatment or drugs your doctor has recommended.

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.

When is it Required?

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.

Why Get Preapproval?

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.

How Do You Get Authorization?

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.

Yes, your doctor may have already approved you for their recommended service or prescription drug, but your health insurance company needs to verify that care is absolutely necessary. They do this for two reasons, 1. To protect you from receiving unnecessary medical treatment, and 2. To save on costs.

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.

Once your doctor recommends a treatment that requires preauthorization the next step is to have him or her contact your insurance provider.

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.

For medical treatments like out-patient or in-patient procedures, your doctor must once again have to contact your insurance company to explain the reason he or she has recommended the procedure and why it is the only way to ensure your health.

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

When coverage for health care services or expensive prescription drugs is denied, you will have to pay in full for the service or medication. However, you do have the right to appeal the decision made by your health care provider. Your benefits documents will have a step-by-step process for how to appeal those decisions.

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.


Frequently Asked Questions

What is precertification in health care?

Precertification, also known as “prior authorization” or “preapproval,” is a process where you’re required to get approval from your insurance provider for certain medical services, even if your doctor has already approved the treatment. It ensures that specific medical procedures or prescription drugs are covered under your insurance policy before you proceed with the treatment.

Why is preauthorization important?

Preauthorization is essential to ensure you are covered for specific medical procedures or prescription drugs. Failing to get preauthorization could mean you pay full costs for services, even if they’re listed in your plan. It prevents unforeseen expenses and penalties from your insurance provider.

Which services typically require precertification?

Some services that often require precertification include home care services, surgical procedures, non-life-threatening ambulance services, radiology exams like X-Rays and MRIs, pain management services, mental health therapies, inpatient facilities, out-of-network laboratory services, specialized pharmaceutical drugs, extensive occupational therapies, and certain vision services.

How can one obtain preapproval from their insurance provider?

Once a doctor recommends a treatment requiring preauthorization, the doctor needs to contact your insurance provider. For prescription medications, the doctor should explain why the drugs are medically necessary. If considering out-of-network treatments, it’s best to contact your provider beforehand to check for possible coverage.

What can I do if my health care service or medication doesn’t get approved?

If your requested service or medication is denied coverage, you’ll have to bear the full cost. However, you have the right to appeal the decision. The appeal process will be detailed in your benefits documents. If a prescribed medication is rejected, your provider might suggest a generic alternative or a different drug they deem effective. If it’s not satisfactory, you can appeal their decision. If challenges persist, you can seek help from customer support teams or professionals.

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