Certification is a review process used to determine if certain services are medically necessary according to HealthChoice guidelines. All certification requests must be submitted through the HealthChoice provider portal
Providers must obtain certification under certain situations, including when the member or the member’s covered dependents:
- Are admitted to a hospital or are advised to enter a hospital;
- Require certain surgical procedures that are performed in an outpatient facility;
- Require certain diagnostic imaging procedures; or
- Have HealthChoice as the second or third carrier.
Certification is required within three business days prior to scheduled hospital admissions, certain surgical procedures in an outpatient facility and certain diagnostic imaging procedures, or within one day following emergency/urgent services. To request certification, the provider must contact the certification administrator.
If certification is not initiated and approved within the time frames described above, but is approved after services are performed, and all other plan rules and guidelines are met, a 10% penalty is applied. The member is not responsible for this 10% penalty. If certification is denied because medical necessity guidelines are not met, either before or after services are performed, the claim is denied.
When using a non-Network provider, the member is responsible for paying the 10% penalty and for any services that are not deemed medically necessary according to HealthChoice guidelines.