In most cases, your provider or hospital will request precertifications
. In the event that you have to request it, you can request this online, via Fax, or by talking to a representative. Requests are prioritized based on medical necessity
. Healthcare procedures, medications or services on the precertification
list of your insurance plan can require you to notify or get a coverage determination. In the case of notification, you just have to file a form to record the healthcare service or procedure you will be receiving, but the insurance company does not have to make a decision on whether to accept to cover you. In the case of precertification
for coverage determination, the insurance company will look at plan documents and clinical information to determine whether to cover that healthcare service, medication or procedure. In the case of emergency services that are on the precertification
list, prior authorization is typically not required and instead you have to notify within 24 hours or the next business day.
For example, your insurance will have a list of medications that are covered, but some are not on this list and require precertification
. If you go to your pharmacy, your pharmacist will contact your insurance to get precertification
. Your insurance will then request a precertification
from your doctor. Your doctor will express the medical necessity
of your medication, and then your insurance will decide based on a medical necessity
criteria whether your insurance can cover the medication. Your pharmacy will then alert you whether you medication was approved or not.