Many international travel medical insurance plans (including visitors insurance plans, student insurance plans) have precertification requirements. A lot of customers may not be completely aware of such requirements. This set of FAQ provides some useful information about precertification requirements.
What is Precertification?
Precertification is only a determination of Medical Necessity. That determination is made based on the completeness and accuracy of the information provided by you and your health care providers at the time of precertification.
What does "Medically Necessary" mean?
A treatment, service, medicine or supply is "Medically Necessary" when it is deemed to be necessary and appropriate for the diagnosis or treatment of an illness or injured based on generally accepted standards of current medical practice. A service, treatment, medicine or supply will not be considered a Medical Necessity if it is provided or obtained only as a convenience to you or your provider; if it is not necessary or appropriate for your treatment, diagnosis or symptoms; or if it exceeds (in scope, duration or intensity) the level of care which is needed to provide safe, adequate, and appropriate diagnosis or treatment.
Under what circumstances do I have to do this precertification?
Even though it varies by the specific insurance plan you have purchased, you would generally need to do the precertification before hospitalization, surgery, CT Scan, MRI, getting durable medical equipment or care in Extended Care Facility or Home Nursing Care.
If it is an emergency, how can I get the precertification before getting the treatment?
Even though the exact timing and deadline for emergency precertification vary by the terms and conditions of the specific insurance policy, generally, you would have to get precertification for emergency hospitlization done within 48 hours or as soon as it is reasonably possible.
What do I have to do with the precertification?
You should call the phone number listed on your insurance card and let them know about it.
Alternatively, in some plans, you can do it online.
Additionally, please notify the providers (such as physicians, hospitals etc.) that your insurance plan contains precertification requirements and ask them to fully cooperate with the Plan Administrator.
I had already precertified my father's surgery and/or the hospitalization. However, the insurance company still rejected the claim later. How is that possible?
Precertification is not a guarantee of benefits. Eligibility for a claim is determined after the insurance company's claim department receives the attending physician statement and all medical records. Based on that, after consulting the insurance policy wording (also called certificate wording), they would determine whether something is a covered expense or not. Until then, there is no basis to make such determination of eligibility.
What is clinical packet?
Clinical packet is sent by insurance administrator to the provider to be completed as part of the precertification process. It is basically the precertification forms where provider fills in needed information to review for medical necessity.
As per specified in the insurance policy, I fulfilled the requirements of the precertification. I had no idea about the clinical packet. And I didn't know that the provider didn't submit the necessary forms. Would I be penalized for incomplete precertification?
Unfortunately, there is no easy answer. Each insurance company will make the determination on a case by case basis.
Once I complete the precertification, do I have to do it again for the same sickness/injury?
Generally, you are precertified for a few days of hospital stay at a time. If a longer stay is required, you may have to do the precertification again. However, it all depends upon the terms and conditions of the specific insurance policy.
What happens if I don't do the precertification when it was needed?
Many policies will reduce the eligible benefits payment by 50% or some by 20%.
I had no idea about such precertification requirements. Is there anyway you can waive this requirement (that is failure to do precertification) for me and pay the full benefits?
Unfortunately, ignorance is not a valid excuse. When you purchased the insurance, and in most cases, even before you purchased the insurance, the insurance certificate wording was made available to you which clearly describes any precertification requirements.
When I called to do the precertification, no responsible person who could do it was available at the insurance company and I was asked to call back on Monday. Would I be penalized based on that?
As long as you called in a timely manner and followed the procedure such as calling back on Monday as advised by them, you would not be penalized for it as it is beyond your control and you did your due diligence.