Pre-certification
What Does Pre-certification Mean?
Pre-certification is the process of getting prior approval from a health insurance company before receiving certain medical services, procedures, or prescription medications. This step ensures the insurer agrees the treatment is medically necessary and may be covered, but it does not guarantee full payment or coverage.
Insuranceopedia Explains Pre-certification
Understanding Pre-certification in Health Insurance
Also known as pre-authorization or prior authorization, pre-certification is a key step in managing healthcare costs and coverage. Insurance companies use this process to evaluate whether a treatment or medication is medically necessary before committing to pay.
Without pre-certification, your insurer may deny coverage, even if the service would normally be included in your plan.
When Is Pre-certification Required?
- Hospital admissions (inpatient and outpatient)
- Surgical procedures
- Specialty medications
- Advanced imaging tests (e.g., MRI, CT scans, PET scans)
- Expensive therapies (e.g., chemotherapy, dialysis)
- Certain mental health or substance abuse treatments
Not usually required for:
- Emergency services
- Routine check-ups
- Preventive screenings like mammograms or blood pressure tests
How the Pre-certification Process Works
- Doctor identifies the need for a specific service or prescription.
- Healthcare provider submits a request to your insurer with relevant medical documentation.
- Insurance company reviews the request to determine if it meets medical necessity and plan criteria.
- Approval, denial, or a request for more info is sent to both the patient and the provider.
This process can take a few days or more, depending on the insurer and complexity of the request.
Why Is Pre-certification Important?
- Avoids unexpected denials or out-of-pocket expenses
- Helps manage healthcare costs for both insurer and patient
- Ensures medical necessity is met before expensive procedures
- Provides clarity on what is or isn’t covered before treatment begins
Final Thoughts
Pre-certification is an essential part of navigating your health insurance plan. It ensures you’re not blindsided by surprise bills and gives your insurer a chance to approve medical necessity in advance. Always check your plan details or speak with your provider to find out if pre-certification is required before receiving care.
