What is Precertification?
A program designed to eliminate unnecessary days in the hospital by reviewing elective hospitalization prior to the patient’s admission. It ensures that the services are necessary and an inpatient setting is appropriate. Some insurance companies will asses penalty or benefit reduction if precertification procedures are not followed.
Before you’re admitted to the hospital as an inpatient, you need to get your stay precertified. Precertification is the process by which we evaluate the medical necessity of your proposed stay and how many days are required to treat your condition. Any stay greater than 23 hours must be precertified, except maternity admission for a routine delivery. OPM requires all Federal Employee Health Benefits Program (FEHBP) plans to precertify hospital stays. In most cases, your physician or hospital will take care of precertification. However, you are still responsible for ensuring that we are asked to precertify your care. So always verify with your physician or hospital that they have contacted us. Warning: We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. We will not change the decision we make on medical necessity, unless we are misled by the information given to us. In addition, if the stay is not medically necessary, we will n
