Precertification
Advocates for Care
Optimum-quality Care. Our fully-integrated precertification service reviews prospective inpatient hospitalizations and outpatient procedures to ensure that all patients receive optimum-quality and cost-effective care. Primary PhysicianCare is an advocate for our members. By enabling members to understand their coverages, we prevent headaches from unpaid medical bills or disputes concerning coverages.
How Precertification Works
Simple Steps Toward Better Care. Prior to a non-emergency admission or outpatient treatment at a hospital, our members or their hospitals contact Primary PhysicianCare's nurse call center for approval. Clinical information is transferred between parties to ensure that the member is eligible for the admission or treatment. Based on national guidelines, the proposed treatment falls into one of three categories:
- Standard therapies that meet evidence-based guidelines. 94% of all precertifications fall into this category. Example: A hospital contacts Primary PhysicianCare on behalf of a pregnant patient to gain approval for a routine delivery and a two-day stay. The patient is healthy and her pregnancy is expected to be full term. A letter goes to the member and the provider acknowledging receipt of the call.
- Non-standard therapies that require investigation and research prior to approval. 3% of all calls have patient-specific needs that require further investigation. Example: A patient is pregnant and is experiencing premature contractions. The physician contacts Primary PhysicianCare to gain approval for medication to be delivered to the patient’s home to hold the contractions at bay. The proposed medication is unique to this patient’s condition but is considered standard therapy within the medical community. In addition, the patient can remain at home rather than become an inpatient in the hospital for several weeks. A letter goes to the member and the provider approving the therapy and the service.
- Non-covered treatments account for 3% of all calls. Example: A patient suffers from obesity and, according to criteria for bariatric surgery, qualifies for the treatment. The treatment is considered medically necessary and standard within the medical community. However, surgical treatment for obesity is not covered under the plan. A letter goes to the provider and the member indicating the proposed treatment is not covered under the plan.
Examples of Services Requiring Precertification:
- Inpatient hospitalizations
- OB admissions
- 23-hour observation stays
- Outpatient surgery
- Home healthcare, home infusion services, and nursing home care
- Durable medical equipment with a purchase price greater than $1,000 and all rental equipment
- Organ transplantation
- Referrals to any nonparticipating physician, other healthcare professionals, medical institutions, and vendors
- Acute/subacute inpatient rehabilitation
- Inpatient hospice
- Inpatient/outpatient chronic pain management MRI, PET or other scheduled radiological scans
Non-network Providers
Most Appropriate Care . Our medical team identifies when the provider of a service is not an in-network provider, and options are discussed with the requesting physician to move the care to a preferred provider. When this is not possible, the case is transferred immediately to the network management team so a proactive negotiation can be made with the non-preferred provider prior to treatment. The result is receipt of the most appropriate care available.
The Difference: Full Integration
Direct Access. Our fully-integrated approach eliminates administrative outsourcing. This means that our medical team enjoys high degrees of infrastructure access. Examples of this access are:
- Direct access to customer service and benefits information. Special plan provisions that affect precertification decisions are known immediately.
- Direct access to our eligibility system and staff for determination of eligibility, COBRA status and other special eligibility provisions.
- Direct access to member network affiliation, network provider search, and network management department.
- Direct access to the claims department to communicate negotiated billing amounts, special precertification requirements and overrides, claim and member level holds.
- Direct access to client services so the client is informed in advance of any upcoming large cases.
- Our medical department uses the precertification module that is built into the DST PowerSTEPP claims system, which is integrated with all other benefit subsystems. The claims system can locate a precertification record automatically during auto-adjudication without user intervention.
