Pre-certification is necessary for two reasons:
One is to determine if the benefit is covered, and
Two, to see if the provider is in net-work.
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Pre-Certification of Procedures
Pre-certification is necessary for two reasons: One is to determine if the benefit is covered, and two, to see if the provider is in net-work.
If you do not pre-certify for a procedure, your benefits will be paid at 50%. If the provider is not in net-work, the fees can be well over the usual and customary charges. These costs above the usual and customary charges can be in the thousands of dollars and they will have to be paid by the member.
My suggestion on the need for pre-certifying injections is twofold: your first call should be to the Health Fund Staff. The Staff will receive your call, research it and contact the doctor if necessary.
Your second call or contact is your doctor. Please ask him to contact the Health Fund and document the need for the injection. Please don’t wait to pre-certify the day before the procedure. You should pre-certify days or weeks before you go for the procedure. Some things can hold up the pre-certification, such miscommunication with the doctor, telephone calls not returned, necessary research to see if the procedure is covered, etc.
As an example, if you were to call the Health Fund office for pre-certification, it could possibly take up to 72 hours to finish the process. You will not be automatically pre-certified by calling the office. Pre-certification is a process that has to be put in motion, however, snags as mentioned above can hinder the process. Once you set pre-certification in motion, don’t sit back and assume all is taken care of.
You must follow through on the same day you request precertification. I MUST STRESS THAT
PRE-CERTIFICATION IS THE ULTIMATE RESPONSIBILITY OF THE MEMBER.