What is the difference in a predetermination, a precertification and a referral?
Predeterminations, Precertifications and Referrals are all mutually exclusive of each other. • Predetermination by Medical Review determines medical necessity based on coverage criteria for planned procedures. • Precertification by Health Management determines appropriate hospital/outpatient setting and length of stay for procedures and/or admissions based on criteria. • A referral must be obtained and/or submitted by the Primary Care Physician (PCP) for recommended specialist or treatment based on specific contract language. Please refer to Customer Service to determine specific contract requirements.
