Pre-Certification (Health Care) Law and Legal Definition

Pre-certification is the process of obtaining eligibility, certification or authorization and collecting information from the health plan prior to inpatient admissions and selected ambulatory procedures and services. It is also known as pre-admission certification, pre-admission review, and ‘pre-cert’.

Notification and coverage determination are the two elements of pre-certification. Notification refers to the process of recording a request for coverage on services or supplies included in the pre-certification list. While coverage determination is based on plan documents and nationally recognized guidelines and it requires review of plan documents, clinical information regarding the service or supply to determine whether clinical guidelines for coverage are met. Pre-certification requests can be submitted through an electronic data interchange (EDI) or internet solution, or by telephone, or in writing by fax or mail. . Failure to obtain pre-certification will impose financial penalty upon the beneficiary or the health care provider.