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4 Things You Need to Know About Precertification

What if there was a way to make sure that you received the right care at the right time, and didn’t get stuck with a surprise medical bill? Well, there is. It’s called precertification. Learn the seven ways it prepares you for success when receiving care.

What if there was a way to make sure that you received the right care at the right time, and didn't get stuck with a surprise medical bill? Well, you're in luck. There is. It's called precertification.

Precertification is the process Blue Cross Blue Shield of Arizona (BCBSAZ) uses to determine what your plan will cover. Your doctor initiates this multi-step process for some medications, medical equipment, and specialized treatments.1 Once your plan benefits are confirmed, the request is evaluated and completed within one to two business days.

The process is not intended to deny or delay the care you may need. Rather, precertification ensures that you receive optimal care while keeping your out-of-pocket costs to a minimum.

Here are four ways that precertification prepares you for success when receiving care: 

1. It protects you financially.
At BCBSAZ, we require precertification for various services and procedures. Some examples include durable medical equipment (such as a walker, crutches, or a wheelchair), MRIs, transplants, genetic testing, and inpatient surgery. Some things are covered by your plan, and some things are not. Precertification is in place to help both you and your doctor avoid unexpected expenses.2

2. It protects against medical errors. 
During the precertification process, we work to confirm that the requested service or procedure is consistent with your medical records. For example, we might see a history of right knee pain in your records, but the request is for a left knee surgery. Our team can help ensure your safety by catching this coding error well before surgery occurs.

3. It can help improve care delivery.
As part of precertification, we consider where you receive your care. For example, one of our members—a young mother of two—had to spend an entire day, every other weekend, at a clinic to receive a special therapy. Our team asked, “Could the care be provided at her home instead?” The answer was “yes.” In the end, we helped improve her quality of life and lower costs by having the same care provided in her home.

4. The majority of requests are approved.
We want you to get the care you need, and we ultimately approve most of the requests we receive. If your precertification is not approved, and the denial was based on lack of information, your doctor will have an opportunity to supply the information that's needed and talk through any other issues.

We’re here to help. 
Our team partners with your doctor to make sure that we receive the information we need, which helps reduce denials and appeals—saving everyone time in the long run.

Our goal is to work with your doctor to do what's best for you. We are committed to making sure that the precertification process is efficient and easy to understand for everyone involved.

If you have questions or need additional information about the BCBSAZ precertification process, visit azblue.com/MyBlue and review the “Precertification Requirements [PDF]”3 document under “Plan Benefits,” or call Member Services at (602) 864-4115.

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Notes:

1. It is preferred that providers initiate the precertification process with BCBSAZ, whether or not they are in your plan’s network.

2. Precertification is not a preapproval or a guarantee of payment. Even if medical necessity is precertified, other terms of your benefit plan still apply, such as limitations, exclusions, waivers, and benefit maximums.

3. The “Precertification Requirements [PDF]” document should be used together with your plan’s benefit book. Please review your plan’s current benefit book to determine which benefits are covered BEFORE referring to the list of precertification requirements.

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Disclaimer

This information is provided for educational purposes only. Individuals should always consult with their healthcare providers regarding medical care or treatment, as recommendations, services or resources are not a substitute for the advice or recommendation of an individual's physician or healthcare provider. Services or treatment options may not be covered under an individual's particular health plan.