Pre-certification

It is important when going in for specific services to make sure that the procedures are certified in advance of the proposed service, except for emergencies. The covered person or their provider should call the pre-certification number on the back of the members ID card prior to admission, procedure or service.

Following is a list of items that qualify for pre-certification:

• Inpatient hospital services.
• Outpatient surgeries in hospital, ambulatory surgical facility or physician’s office (if there is an operating room charge). Outpatient observation stays.
• The following outpatient procedures:
  • Cardiac catheterization
  • Arthroscopy
  • CT’s/MRI’s
  • Nuclear studies
  • Endoscopies (including laparoscopy, but not sigmoidoscopy)
  • Rehabilitation (inpatient)
  • Extended care facility and sub acute facility services.
  • Dental procedures performed in the hospital or ambulatory surgical facility
  • Durable Medical Equipment (DME) in excess of five hundred dollars ($500)
  • Home health care

Covered persons should contact the Utilization Review Organization by calling the toll free 800 number on the back of their ID card.