Pre Certification

A requirement that you obtain the insurance company’s approval before a medical service is provided. If you fail to follow the pre-certification procedures the company may reduce or deny claim payment. Please note: getting pre-certification does not guarantee claim payment. Also called Utilization Review.

A utilization management technique that requires a healthcare insurance plan member or the physician in charge of the member’s care to notify the plan, in advance, of plans for a patient to undergo a course of care such as a hospital admission or complex diagnostic test. Also known as prior authorization.

Prior Authorization

Prior authorization is a requirement that your physician obtain approval from your health plan to prescribe a specific medication for you. Without this prior approval, your health plan may not provide coverage, or pay for, your medication.

In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical-necessity review. See also precertification.

Both are similar.

preadmission testing

A utilization management technique that requires health insurance plan members who are scheduled for inpatient care to have preliminary tests, such as X-rays and laboratory tests, performed on an outpatient basis prior to admission.

primary source verification

A process through which an organization validates credentialing information from the organization that originally conferred or issued the credentialing element to the practitioner.