Download Insurance Pre-Certification

Policies and Procedures
Function: DEPARTMENTAL POLICIES AND
PROCEDURES
Department: Registration/PBX
Subject:
Reference No:
6.3
Page:
1
INSURANCE PRE-CERTIFICATION
Scope:
Department
Of
3
One requirement of health insurance coverage is pre-certification. Pre-certification is the process in
which an insurance company is notified of an inpatient admission or outpatient service before the
service is rendered. Notification to the insurer allows them the opportunity to review the diagnosis
and symptoms to ensure that the pending treatment falls within the guidelines of the health plan
coverage. Pre-certification also helps ensure that the patient will receive the maximum benefits
available under the health plan; however, it does not guarantee payment for the service.
If a patient receives a service that the insurance company has indicated requires pre-certification and
the company has not been notified in a timely manner, the risk is run that the insurance provider will
deny the claim or reduce the benefits. The consequences of failure to pre-certify, when it is required,
may result in a 25% reduction in benefits or as much as a $500 penalty. Pre-certification is ultimately
the responsibility of the patient; however, the hospital assumes this responsibility in an effort to collect
optimal reimbursement from insurance companies and not incur penalties or reduction of benefits.
Pre-certification is a process that takes, in most cases, approximately 10-15 minutes and can be done
over the phone. The phone number for pre-certification is often printed on the insurance card, which
the registration clerk is required to photocopy, back and front. To help ensure a smooth precertification process, all of the required information should be prepared prior to initiating the call. The
pre-certification representative that will be collecting information will ask for the patient’s name, the
insured’s name, the insured’s ID number, the physician’s name, the place of service, the date of
service, the type of service, and the patient’s diagnosis or symptoms. In addition, the representative
may ask the hospital’s address, the physician’s address, phone numbers, the hospital’s tax ID
number, or the hospital’s provider number. The representative will then assign a number, which may
be an authorization number, tracking number, or reference number. You are required to complete the
pre-certification form provided for forwarding to Utilization Review; the UR department personnel will
then, if necessary, conduct a review of the patient’s chart and contact the review company with
“clinicals” [history, physical findings, lab and x-ray results, treatment planned – medications,
procedures, etc. – , estimated length of stay, post-discharge plans, etc.]. The pre-certification form
requires the patient’s name and hospital number, the date of contact with the insurance company,
who was spoken with at the insurance company and who made the contact, and the results of the
contact….no pre-certification required, pre-certification performed previously [in which case, the
number and assigned days should be recorded], etc. In those cases where contact is required by
Utilization Review, a contact person and number should be recorded on the form as well. This form is
then forwarded to the utilization review department.
Reviewed:
Revised:
Accepted:
Policies and Procedures
Function: DEPARTMENTAL POLICIES AND
PROCEDURES
Department: Registration/PBX
Subject:
Reference No:
6.3
Page:
2
INSURANCE PRE-CERTIFICATION
Scope:
Department
Of
3
Companies have different policies as to what needs pre-certification and when pre-certification takes
place. Elective surgical procedures and some scheduled outpatient procedures, MRIs, and some xray procedures must be pre-certified prior to the patient receiving services. The physician’s office is
in possession of information necessary for the process which the hospital does not have, and in some
cases must be contacted to obtain this information or to contact the company directly. Occasionally
documentation of the pre-cert will accompany the patient or have been faxed to the hospital
previously. If not, contact must be made with the physician’s office to obtain the documentation at
the time of registration. If necessary, an explanation is to be made to the patient that this process
must take place to avoid the patient assuming financial responsibility for the service because of lack
of approval by the insurance company. Emergencies are a different matter, but even those must be
reported to the company within a specific time limit. At the least, pre-certification must take place
within 24 hours of the service being rendered. Although the majority of insurance companies do not
have human contact available 24 hours a day, most have computerized/voice mail capability. Precertification done after the 24-hour limit falls into a “delayed notification” category and carries with it a
penalty, as stated above, for non-notification. The rule of thumb for pre-certification is: If in doubt
whether the pre-certification is required/has been obtained, phone to find out. Rules often change
within the insurance companies, and simply because the previous week the particular insurance
company did not require pre-certification, it is not to be assumed that this week it still does not.
The Utilization Review Department should be contacted immediately in the event of any problems,
and if appropriate, the patient’s financial class is to be revised. Example: The admitting clerk is
informed that coverage by the insurance company provided by the patient has expired. In this event,
the patient should be contacted for verification of this and if this is indeed true, the patient’s financial
class becomes self-pay, in which case Financial Assistance is to be notified by means of a new face
sheet.
Pre-certification should be part of each individual registration clerk’s process in admitting a patient, in
the same way verifying Medicaid coverage is part of the process. Each clerk will be trained to do precertification and will proceed to do so at the time of a patient’s admission or as soon as time allows.
A clerk not otherwise occupied may perform the pre-certification for another clerk occupied with
admitting another patient, but it will be ultimately the responsibility of the clerk admitting to pre-cert.
Because of the notification time limits imposed by all insurance companies, it is imperative that precertification be done as quickly as possible, remembering that providing clinicals is part of the process
Reviewed:
Revised:
Accepted:
Policies and Procedures
Function: DEPARTMENTAL POLICIES AND
PROCEDURES
Department: Registration/PBX
Subject:
Reference No:
6.3
Page:
3
INSURANCE PRE-CERTIFICATION
Scope:
Department
Of
3
In most cases, and in order that this can be done within 24 hours, utilization review personnel must
be notified in a timely manner. While no insurance company has yet imposed a strict, to-the-minute
24-hour deadline, a pre-cert done at 4 p.m. on a patient admitted the previous day does not allow UR
personnel ample time to comply with the 24-hour deadline. After hours, a clerk may attempt precertification and proceed as usual when the insurance company has voice mail, etc. If not, the precert may be left for clerks the following day, and clerks the following day will do pre-cert as soon as
time allows.
Note: Most insurance companies do not require pre-cert for medical short stay (observation), but still
need to be contacted. Also, when a patient is admitted as an inpatient from observation, the
insurance company must be called again with the new information so that pre-certification
requirements are satisfied.
Reviewed:
Revised:
Accepted: