Definition of an Insurance Precertification Form

Insurers and medical providers often use "precertification" and "preauthorization" interchangeably. You will typically use the precertification form to obtain preapproval when you require inpatient services, surgeries or certain medications. Precertification is standard in health management organizations, and many insurers use the precertification process to coordinate planned medical treatment for all plan types.

Purpose

• The precertification form notifies your insurer of the service you will receive along with the date and place of your procedure. The form lists your name, date of birth, residential address and contact details. Your provider may also provide the details of your illness with the specifics regarding your expected length of stay and your progress since prior treatments. This information is sometimes conveyed via the physician notes and your medical records, which may be sent in with the form. If you are the policyholder but not the patient, the form may also detail your personal and policy information. Details of physicians and facilities providing the services will also appear on the form.

Function

• While some precertification forms are quite simple and serve only to notify the insurer of your intended treatment, others are extremely detailed as the insurer may use the form to coordinate benefits and determine coverage. Usually, the main function of the form is formal notification of services. Insurers then review the information from the precertification along with any supporting documentation to determine the medical necessity of your treatment.

Considerations

• Bear in mind that precertification is not the same as preapproval for claim payment. Although your insurer may grant a "preapproval" based on information submitted on the form, this is not a guarantee that you will receive reimbursement for all expenses associated to your preauthorized care. You should consult with your policy information and your insurer's benefit coverage department to determine actual insurance coverage for your procedures and medications. Also, note that use of the precertification form is not mandatory. Some insurers accept precertification via the telephone, Internet or a letter.

Warning

• Insurers do not require precertification for all services, but there are certain procedures and medicines for which your insurer may reduce coverage if you neglect to obtain preauthorization. The onus of obtaining prior authorization typically lies with you and your providers. Some insurers will charge you a higher deductible if you neglect to obtain preauthorization for certain treatments. In some cases, your insurer may deny your claim. In the HMO environment, your primary care physician or the treating physician must obtain the preauthorization. If they neglect to do so, and your claim is denied, the HMO does not allow the provider to bill you for the denied payments.