What is pre-certification (pre authorization, prior authorization)?
Pre-Certification is an authorization given by your insurance company after you Initial Evaluation to each patient for a specified number of visits. Pre-Certification is not a guarantee of payment. It also requires to identify the service is medically necessary for outpatient hospital services in connection with medical, dental Procedures.
Precertification or prior authorization: The prospective process whereby licensed clinical associates apply designated criteria sets against the intensity of services to be rendered, a member’s severity of illness, medical history, and previous treatment to determine the medical necessity and appropriateness of a given request. If a service requires precertification, the provider must contact Amerigroup Community Care via phone, facsimile or electronic communication to obtain approval prior to the rendering of services. All relevant clinical information needed to determine medical necessity must be included in the request for prior authorization.
Cardiac rehabilitation Precertification is required for coverage of all services.
■ Procedures related to the administration of approved chemotherapy medications do not require approval when performed in outpatient settings by a participating facility, provider office, outpatient hospital or ambulatory surgery center.
■ For information on coverage of and precertification requirements for chemotherapy drugs, please refer to the Precertification Lookup Tool from the Quick Tools menu on our website.
■ Precertification is required for coverage of inpatient chemotherapy
■ No precertification is required for Evaluation and Management (E&M, testing and most procedures).
■ Services considered cosmetic in nature or related to previous cosmetic procedures are not covered.
■ See the Diagnostic Testing section of this QRC for more information.
■ No precertification is required for routine diagnostic testing.
■ Precertification is required for coverage of video EEG.
■ For observation precertification requirements, see the Observation section of this QRC.
ENT services (otolaryngology)
■ No precertification is required for network provider E&M testing and most procedures.
■ Precertification is required for tonsillectomy and/or adenoidectomy, nasal/sinus surgery and cochlear implant surgery and services.
No precertification is required for network provider for E&M, testing and most procedures.
■ Precertification is required for upper endoscopy and bariatric surgery, including insertion, removal and/or replacement of adjustable gastric restrictive devices and subcutaneous port components.
■ Precertification is required for digital hearing aids for members under 21 years of age.
■ No notification or precertification is required for coverage of diagnostic and screening tests, hearing aid evaluations and counseling.
Home health care
Precertification is required and can take up to 14 days for a decision. For continuing home care services, the requested should be received at least two weeks prior to the end of the authorization period. In order for home care services to be reviewed, the initial requests must have a current MD order, clinical documentation to include the nurse and/or therapy evaluation. For concurrent home care services, documentation shall include the most current signed 485, nurses/therapy/home health aide notes
■ Precertification is required for the following covered services: skilled nursing, home health aide, therapy, home infusion.
■ Rehabilitation therapy, drugs and DME require separate precertification.
Coordinate all medical supply referrals through Amerigroup Utilization Management (UM) at 1-800-454-3730. You can fax referral requests to 1-877-423-9958. No precertification is required for coverage of disposable medical supplies. Disposable medical supplies are disposed of after use by a single individual. Over-the-counter (OTC) disposable medical supplies are not covered.