Pre-certification of care is also the responsibility of the Employee or Covered Person. Know your medical plan. All health plans have some services that require approval prior to receiving care. You should check your plan to see which procedures/care require pre-certification. You will need to work with your provider in obtaining authorization for proposed care. Please let your provider know that the care that you are about to receive requires pre-certification. Your provider will then need to submit clinical information to the pre-certification department representing your medical plan.
Pre-certification of scheduled inpatient, outpatient surgery, or other deemed procedures should be pre-certified at least 10 working days prior to receiving care. The Precert Department may need to communicate several times with your provider to get the information necessary for authorization. There may also be times when a second opinion may be required; therefore the greater the advanced notice the better. Emergency inpatient admissions must be reported within 24 hours of the next business day after an emergency admission. Failure to pre certify before services are rendered will result in reduced benefit coverage, denial of benefits, or having a monetary penalty applied.
Please note that pre-certification is not a guarantee of payment, only medical necessity; benefit payments are subject to Plan provisions.
What must I do in case of a hospital admission?
Before an elective admission to the hospital, you or your physician must call the Utilization Management/Pre-certification number on your ID card. Advanced notice requirements vary according to benefit plans. Call your benefit administrator or your employer's Personnel Office for information. The utilization review staff will review the treatment plan with your physician to determine medical necessity of your admission. This process is called pre-certification. If your hospital stay is not pre-certified, your plan benefits may be reduced.
What services require prior authorization by the Utilization Management Department?
The procedures that require pre-certification will vary by health plan. All hospital inpatient services must be authorized prior to the date of admission. The Utilization Management Department must be contacted no later than two (2) working days after any emergency admission. To contact Volusia Health Network's Utilization Management Department, call 386.425.4846 or 800.741.2198.
What should I do if a medical emergency occurs?
If you have an emergency medical problem, if possible, go to the nearest participating Volusia Health Network hospital. Pre-certification is not required prior to an emergency admission. In a life-threatening emergency, go to the nearest hospital emergency room.
Call the number listed on your ID card within 24 hours after an emergency admission. The attending physician, a hospital representative or the patient's family may make contact. If you fail to call, your benefits may be reduced.
Some surgical procedures must be performed on an outpatient basis to obtain the maximum coverage. Contact the Utilization Management/Pre-certification number listed on your ID card for information about procedures that require outpatient services. Some health plans require pre-certification of certain outpatient testing. Review the employee benefits manual supplied by your employer for specific utilization review requirements