Some health services require precertification. You know everything about them here.

Our Pre-Certification Program evaluates your request for services, whether it is a study or a procedure before the services are performed.

Precertification validates your medical necessity and prevents risks to beneficiaries, as well as promotes stability and consistency in medical determinations.

The following criteria are used when evaluating your pre-certification application:

• The severity of the condition
• The intensity of services
• Medical justification for the requested service
• Interqual Guides
• Existing Medical Policy
• Medical Advisory Panel

The minimum requirements to work on your application are:

• Patient's full name
• Contract number
• Medical order that includes all the clinical information necessary to make a decision
• CPT or ICD9 Code
• Previous studies (if applicable)
• References (if applicable)

All this information must be received by fax.

Services requiring pre-certification

The services or procedures that require pre-certification vary according to your line of business and policy. It is important to validate with the Customer Service Department or Supplier Service in case of doubt whether a service requires pre-certification or not.

The following services always require pre-certification:

• The severity of the condition
• MRI
• CT Scan
• Pet Scan
• Cosmetic Surgery

When the required service meets all established criteria, the provider and the insured will be informed of the authorization number by telephone and mail. Precertification will be effective for 30 calendar days.

When the service is denied, a letter will be sent to the patient and provider detailing the reasons for the denial. In the same letter, the insured person will be informed of his/her right to appeal the decision.