Prior approval for medical services (precertification)
For certain services, HMSA requires that you or your physician obtain approval before the services are rendered to ensure that they meet our guidelines for payment. During the approval process, we verify that your plan benefits cover the service, that the service meets HMSA’s payment determination criteria, and that it follows generally accepted medical practice. This review and approval process is called “precertification.” Precertification is required for certain medical treatments, procedures, places of treatment, and devices.
Why HMSA requires precertification
We take our responsibilities to our members seriously. Our precertification standards are established for the safety of our members, to promote appropriate utilization of services, and to keep health care costs in check.
Services that require precertification
Your Guide to Benefits lists medical treatments, procedures, and devices that require precertification. Because your Guide to Benefits is updated annually, the list of services that require precertification may change during your plan year. To see if a service requires precertification, review the Services That Require Precertification list, or call HMSA Customer Relations.
Precertification does not guarantee payment
Please note that obtaining precertification does not guarantee payment for services. A precertification only confirms whether a service meets HMSA’s payment determination criteria at the time of the request. Even if precertification is approved, your claim may deny or payment may be reduced (for example, when a loss or change of coverage occurs).
For additional important information, we encourage you to read: