• Inpatient hospital admission, inpatient residential treatment center admission
   

Precertification is the process by which – prior to your inpatient admission – we evaluate the medical necessity of your proposed stay, the procedure(s)/service(s) to be performed, the number of days required to treat your condition, and any applicable benefit criteria. Unless we are misled by the information given to us, we will not change our decision on medical necessity.

In most cases, your physician or facility will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician, hospital or inpatient residential treatment center whether or not they have contacted us and provided all necessary information. You may also contact us at the phone number on the back of your ID card to ask if we have received the request for precertification. You are also responsible for enrolling in case management and working with your case manager if your care involves residential treatment. For information about precertification of an emergency inpatient hospital admission, please see page 26.

Note: Special rules apply when Medicare or another payer is primary, see pages 23-24.

Warning:

We will reduce our benefits for the inpatient hospital stay by $500, even if you have obtained prior approval for the service or procedure being performed during the stay, if no one contacts us for precertification. If the stay is not medically necessary, we will not provide benefits for inpatient hospital room and board or inpatient physician care; we will only pay for covered medical services and supplies that are otherwise payable on an outpatient basis.

Note: If precertification was not obtained prior to admission, inpatient benefits (such as room and board) are not available for inpatient care at a residential treatment center. We will pay only for covered medical services and supplies that are otherwise payable on an outpatient basis.

Exceptions:

You do not need precertification in these cases:

You are admitted to a hospital outside the United States; with the exception of admissions for gender affirming surgery and admissions to residential treatment centers.

Note: Special rules apply when Medicare or another payer is primary, see pages 23-24.