Prior Approval Information

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BlueAdvantage National Accounts

Inpatient/Outpatient Hospitalization Admission Precertification<

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Pre-certification / Pre-notification:

Preadmission certification or pre-certification

The process of obtaining authorization for emergent/acute or future medical inpatient admissions is pre-certification. Pre-certification may also be required for designated outpatient services/procedures based on the member’s plan description. The process involves evaluation for medical necessity utilizing MCG guidelines. MCG guidelines can be found at the following link: http://www.mcg.com/payor/product/carewebqi-payors

Pre-notification

The process of pre-notification is the receiving of information from health care providers related to an inpatient medical admission. Pre-notification may be required based on the member’s plan description. If required, admission information is entered into the documentation system or platform.

Pre-authorization / Prior authorization:

Prior authorization or pre-authorization is a review prior to the time a specified procedure is scheduled. This review consists of checking clinical documentation to verify the medical necessity for the procedure and whether the service meets the criteria established under the health benefit plan. A prior authorization is required for each different procedure as indicated as required in the Summary Plan Description. Failure to obtain prior authorization will result in denial of the claim.

Procedures requiring prior authorization: