Surgery pre-certification, prior authorizations

Follow these steps to handle the surgery pre certifications and prior authorizations. Know the difference between pre-certification and prior authorization.

Categorized as Operations Tagged
Surgery-prior-authorization-checklist-ezhcrm-1

Follow these steps to handle the surgery pre certifications and prior authorizations. This should ensure your surgery booking booking process is spot-on.

  1. Get the pre-certification

    After the patient leaves, you, the surgery scheduler should start getting the needed pre-certification from the payer.

    Note the differences between a pre-certification and a prior authorization

    The terms pre-certification and prior authorization are often used interchangeably.

    These two are mutually exclusive of one another. You do not need to send documents to support medical necessity for pre-certification.

    If it is a non urgent or elective surgery, then you need to send a pre-certification request to the payer first.

    The payer will let you know whether the requested procedure is covered or not. This is similar to an eligibility request in that you do not need to submit any medical documentation.

  2. Call patient to discuss the precertification denial (if any)

    If and when the payer responds to the pre-certification request with a denial (i.e. surgery is not covered by the patient’s plan), then you, the surgery coordinator need to discuss with the patient and the surgeon about next steps.

  3. Submit the prior authorization related documents

    Preauthorization isn’t a promise the patient’s health insurance or their specific health plan will cover the cost of the surgery.

    Pre-authorization is step 2 for non-urgent or elective services.

    For prior authorization you need to send medical records and physician documentation to prove medical necessity.

    Send the prior authorization with the visit note and all surgery related documents to the payer in this step.

  4. Handle emergency procedure prior authorizations retroactively

    Meanwhile, if it is an emergency procedure, the surgical coordinator can skip the pre-certification process and try to get the prior authorization retroactively after the surgery.

    Various payers stipulate that such prior authorizations should be obtained between 24 and 72 hours after admission.

  5. Use a project management tool or surgery scheduling software

    Using EzHCRM, you would do it like this (see image).