Our Services
Pre Authorization Determination
Pre-Authorization & Pre-Certification
Ensuring Necessary Approvals for Patient Care
When treating patients, providers often need to get approval from the patient’s insurance company for certain services in advance. This process, known as pre-authorization and pre-certification, has been introduced by medical aid organizations to ensure that services are medically necessary and to manage costs effectively.
At Vox RCM, our skilled team of authorization agents handles both technical and non-technical aspects of authorization and certification, ensuring efficient processing and reducing unnecessary costs.
Understanding Pre-Authorization and Pre-Certification
Pre-authorization requires providers to obtain permission from the insurance company before delivering a service. This ensures that the service is covered under the patient’s contract and that the patient has available benefit dollars. Authorization can sometimes be granted retroactively, such as within 24 hours after emergency care.
Pre-certification involves the payer reviewing the medical necessity of a proposed service and issuing a certification number before a claim is paid. This is common for elective surgeries, where a physician or nurse with the payer reviews the medical records to confirm the procedure’s appropriateness.
Pre-determination is an early review by the insurer’s medical staff to decide if a treatment is appropriate and if the health plan will reimburse it. This process is completed before treatment begins, providing clarity on coverage.
Providers contact the payer to obtain the necessary approvals, receiving an authorization or certification number to attach to claims. Patients are typically not involved in this process.
If providers do not obtain the required financial clearance before services, the payer may deny the authorization requests. Providers have the right to appeal denials through several levels, including an administrative law judge, according to the contract with the payer or state insurance laws.