PRE-CERTIFICATION AUTHORIZATION (prior authorization, pre-approval, or pre-certification)

PRE-CERTIFICATION AUTHORIZATION (prior authorization, pre-approval, or pre-certification) It is a process commonly used in health insurance plans. It requires approval from the insurer before a specific medical service is provided to the insured patient. A cost containment technique which requires physicians to submit a treatment plan and an estimated bill prior to providing treatment. This allows the insurer to evaluate the appropriateness of the procedures, and lets the insured and the physician know in advance which procedures are covered and at what rates benefits will be paid. Purpose: -Cost Control: Health insurance companies utilize pre-authorization to manage healthcare costs by ensuring that only medically necessary and cost-effective services are covered. -Quality Care: It can also play a role in ensuring appropriate treatment is provided by reviewing if the proposed service aligns with established medical guidelines. -Utilization Management: Pre-authorization is a form of utilization management used by insurers to monitor how often certain services are used and potentially identify areas for cost savings. Who is Involved in a pre certification approval? 1- Healthcare Provider: Responsible for submitting the pre-authorization request with all necessary medical justification. 2- Insurance Company: Reviews the request and determines approval or denial based on policy terms and medical necessity. 3- Policyholder (Patient): Ultimately impacted by the pre-authorization decision; may experience delays in care if approval is pending or denied. The pre-approval process; ~Typically, the healthcare provider, such as a doctor or hospital, initiates the pre-certification process. ~They submit a request to the insurance company, providing details about the proposed treatment plan, including:-Diagnosis-Recommended procedure or medication- Expected costs. ~The insurer reviews the request against the policy terms and medical necessity criteria. ~Based on their review, the insurer will issue one of three decisions; A- Approval: The service is deemed medically necessary and will be covered by the insurance plan. B- Denial: The service is not considered medically necessary, and the insurance company will not provide coverage. C- Request for Additional Information: The insurer may require further details or clarification from the healthcare provider before making a decision If your pre-authorization request is denied, you have the right to appeal the decision by following the procedures outlined by your insurance company. #BeNewinsurance #InsurTech #inclusiveinsurance #insurance #reinsurance #takaful