BlueAdvantage National Accounts
Inpatient/Outpatient Hospitalization Admission Precertification<
Would you like to check the status of a Pending Or Existing Precert?
Pre-certification / Pre-notification:
Preadmission certification or pre-certification
The process of obtaining authorization for emergent/acute or future medical inpatient admissions is pre-certification. Pre-certification may also be required for designated
outpatient services/procedures based on the member’s plan description. The process involves evaluation for medical necessity utilizing MCG guidelines. MCG guidelines can be
found at the following link: http://www.mcg.com/payor/product/carewebqi-payors
The process of pre-notification is the receiving of information from health care providers related to an inpatient medical admission. Pre-notification may be required
based on the member’s plan description. If required, admission information is entered into the documentation system or platform.
Pre-authorization / Prior authorization:
Prior authorization or pre-authorization is a review prior to the time a specified procedure is scheduled. This review consists of checking clinical documentation
to verify the medical necessity for the procedure and whether the service meets the criteria established under the health benefit plan. A prior authorization is required for each
different procedure as indicated as required in the Summary Plan Description. Failure to obtain prior authorization will result in denial of the claim.
Procedures requiring prior authorization:
Carelon Medical Benefits Management — Specified high tech radiology procedures, MRI's, CT's, PET scans, and nuclear cardiology, must have prior authorization.
Inpatient services, emergency room services and observation room services are not subject to this review. For prior authorization, call Carelon at 866-688-1449.
Detailed information regarding the new prior authorization program for outpatient diagnostic imaging services is provided in the Q&A document.
(View Precert FAQ [pdf, 432 KB]
Lucet — (Still applies if insurance is secondary payor.) For authorization, call Lucet at 1-877-801-1159.
1) Inpatient stays
2) Emergency admission (next business day)
3) Partial hospitalization program
4) Intensive outpatient program.