Preauthorization/Precertification of a Medical Procedure
Pre-certification is a requirement found in many health insurance policies; it requires certain medical services must be okayed in advance. If prior approval for a treatment is not received, many policies have significant monetary penalties of up to $1,000 or more.
Advantages to the pre-certification process ensure you are getting the maximum benefits from your plan and it helps protect you from unnecessary hospital confinements or medical treatment.
Denial of a Preauthorization/Precertification
When a preauthorization is denied, there are some options available to you. You or your medical provider can contact the insurance company and request an appeal reconsideration or grievance of that decision.
Each insurance company who conducts preauthorization reviews must have a grievance or appeal procedure that must be disclosed with all denials. Sometimes informal contacts to discuss the decision can be effective as well.
In addition, a person could ask the Division of Insurance for assistance. A person can file a complaint by e-mail or by calling 605.773.3563.