Precertification vs Preauthorization in Healthcare: A Comprehensive Guide

Precertification and preauthorization are often used interchangeably, but they have distinct meanings in the healthcare industry.

Precertification is a process that ensures a patient's insurance coverage for a specific treatment or service before it's provided.

Preauthorization, on the other hand, is a more specific process that requires a healthcare provider to get approval from the patient's insurance company before performing a particular procedure or service.

In some cases, preauthorization may be required for specific treatments, such as surgeries or hospitalizations, to ensure that the patient's insurance covers the costs involved.

Both precertification and preauthorization aim to prevent unexpected medical bills and ensure that patients receive necessary care while minimizing financial burdens.

Intriguing read: What Is a Preauthorization Hold

Precertification is a specific requirement that involves reviewing whether a proposed service is medically necessary. This is usually the case for patients taking part in elective surgeries, as mentioned in Example 2.

Pre-certification involves a payer needing to review whether the proposed service is medically necessary, or not. This is a more specific requirement compared to pre-service requests or pre-service claims.

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A claim number must be provided as proof before a claim can be paid, if the procedure is deemed necessary. This is a crucial step in the precertification process.

Here are some examples of services that may require precertification:

It's worth noting that pre-certification is not the same as pre-service requests or pre-service claims. Pre-service requests are a courtesy review performed by BCBSKS, as mentioned in Example 1. Pre-service claims, on the other hand, are requests for a claim's decision when prior authorization of the services is required by BCBSKS.

Pre-service claims are a request for a claim's decision when prior authorization of services is required by BCBSKS.

Pre-service requests are a courtesy review performed by BCBSKS to determine coverage for items or services that don't require prior authorization. These requests can include services, supplies, or prescription drugs that have a medical policy, are high-cost, or could be deemed experimental/investigation.

Some examples of pre-service requests include:

Pre-certification is a more specific requirement that involves a payer reviewing whether the proposed service is medically necessary. If the procedure is deemed necessary, a claim number must be provided as proof before a claim can be paid.

Prior authorization, on the other hand, is a process that requires a payer to review and approve a claim before it can be paid. This is usually the case for patients taking part in elective surgeries.

Some examples of prior authorization requirements include:

To initiate the prior authorization process, you'll need to review the criteria and fax or email a completed prior authorization form.

Precertification and preauthorization are two related but distinct processes. Precertification serves as a checks and balances system to prevent fraud and inappropriate use of insurance benefits.

The main difference between precertification and preauthorization is the timing and purpose. Preauthorization is a process that occurs before treatment, where healthcare providers obtain approval from the insurance company for specific procedures or medications. This is done to ensure that treatments are medically justified before they are carried out.

Precertification, on the other hand, is not explicitly defined in the article sections, but it seems to be used interchangeably with preauthorization in some cases, such as in Example 1, where it's mentioned as a checks and balances system to prevent fraud. However, in Example 3, it mentions "preauthorization" and "authorization post-service" as two separate processes, suggesting that precertification might be a broader term that encompasses both.

Pre-authorization is a process where healthcare providers obtain approval from a patient's insurance company before performing specific procedures or prescribing certain medications. This helps ensure that treatments are medically justified before they are carried out.

Pre-authorization is required for services that have several alternatives at different costs, are new or expensive, or carry the potential for overuse or misuse.

Pre-certification is similar to pre-authorization, but it's specifically used for inpatient admissions, unless the admission is for a medical emergency, a life-threatening condition, for obstetrical care, or occurs outside the 50 United States.

Here are some examples of what requires pre-certification:

Predetermination is a process where the proposed service is reviewed for medical necessity, and the payment from the insurance company, as well as the patient's responsibility, is determined and confirmed before the procedure is performed. This process can take between 30 to 45 days, and detailed patient information is required.

Precertification and preauthorization are often used interchangeably, but they have distinct differences. Precertification is a proactive measure that helps ensure the proper use of insurance benefits and prevents unnecessary costs.

Preauthorization, on the other hand, is about getting approval for procedures beforehand. This is usually done to ensure that the insurance company is on board with the treatment plan.

In emergency situations, preauthorization might not be feasible due to the urgency of care required. In such cases, authorization is applied after services are rendered.

There are also situations where a medical professional performs extra treatments or services during a procedure that weren’t planned for or covered by the preauthorization beforehand. These situations require authorization post-service.

Emergency medical services, post-acute care services, and follow-up care for previously approved surgeries or treatments are some examples of scenarios where authorization is applied after services are rendered.

Here are some key differences between preauthorization and authorization:

Delays in either procedure can hinder prompt patient access to necessary care, causing frustration and potential health risks.