What is pre-certification and when is it required?
A. Pre-certification is obtaining authorization from the health plan for a hospital admission, or other services as defined in the Summary Plan Description (SPD). Failure to obtain pre-certification may result in a financial penalty or denial of benefits, as outlined by the employer’s benefit plan. Pre-certification requirements vary by employer. Please refer to your SPD for specific plan requirements, or contact Wells Fargo Third Party Administrators, Inc.’s Customer Service Department at 1-800-624-8605. Please note: Summary of benefits and/or eligibility is not a guarantee of payment. Benefit determinations will be based on eligibility and plan limits at the time services are rendered. Benefits information only applies to procedures and diagnoses that are covered by the plan. We encourage you to review the SPD to determine if the charges in question are covered expenses. Pre-authorization requests for a specific diagnosis or procedure must be submitted in writing.
Related Questions
- What are the pre-certification requirements for inpatient hospital confinements, maternity or residential treatment care?
- How does NMHPA affect prior authorization or pre-certification for a hospital stay in connection with childbirth?
- If a patient refuses to sign consent to release information, is a pre-certification call still required?
