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What Precertification Means for Your Health Insurance Coverage

Summary:Learn about health insurance precertification, a process that requires approval from your insurance provider before certain medical services. Find out why it's necessary and how to obtain it.

What Precertification Means for Your Health Insurance Coverage

As a health insurance policyholder, you may have encountered the term "precertification" before. Precertification is an important process that you need to be aware of when it comes to your health insurance coverage. In this article, we will explain what precertification means and how it affects your insurance benefits.

What is Precertification?

Precertification, also known asprior authorization, is a process that requires you to obtain approval from your health insurance provider before receiving certainmedical servicesor procedures. This process is designed to ensure that the medical service or procedure is medically necessary and appropriate for your condition and that it is covered by your health insurance plan.

Why is Precertification Necessary?

Precertification is necessary because it helps to controlhealthcare costsby preventing unnecessary or inappropriate medical services or procedures. It also ensures that policyholders receive the appropriate treatment for their conditions, which can lead to better health outcomes. Precertification also helps to preventinsurance fraudby verifying that the medical services or procedures are being performed by licensed and qualified healthcare providers.

What Medical Services Require Precertification?

The types of medical services or procedures that require precertification vary depending on your health insurance plan. Some common examples of medical services that require precertification include hospital admissions, surgeries, diagnostic tests, and certain prescription medications. It is important to carefully review your health insurance policy to determine which medical services require precertification.

How Do I Obtain Precertification?

To obtain precertification, you will need to contact your health insurance provider and provide them with the necessary information, such as the name of the healthcare provider, the type of medical service or procedure, and the reason for the service or procedure. Your healthcare provider may also need to provide additional documentation to support the medical necessity of the service or procedure. It is important to obtain precertification before receiving the medical service or procedure to avoid any potential out-of-pocket costs.


In summary, precertification is an important process that you need to be aware of when it comes to your health insurance coverage. It helps to ensure that you receive the appropriate medical services or procedures for your condition and that they are covered by your health insurance plan. If you have any questions about precertification or your health insurance coverage, it is important to contact your health insurance provider for assistance.

Tips for Choosing the Right Health Insurance Plan

When choosing a health insurance plan, it is important to consider your individual healthcare needs and budget. Here are some tips to help you choose the right health insurance plan:

1. Determine your healthcare needs and budget.

2. Consider the type of health insurance plan, such as a PPO, HMO, or POS.

3. Review the network of healthcare providers to ensure that your preferred providers are included.

4. Review the coverage and benefits offered by the plan, such as deductibles, copays, and coinsurance.

5. Compare the premiums and out-of-pocket costs of different plans.

6. Consider any additional benefits offered by the plan, such as wellness programs or telemedicine services.

Case Study: How Precertification Can Help Control Healthcare Costs

John is a health insurance policyholder who needs to undergo a knee replacement surgery. Before the surgery, John's healthcare provider obtains precertification from his health insurance provider to ensure that the surgery is medically necessary and covered by his plan. The precertification process helps to prevent unnecessary or inappropriate medical procedures and ensures that John receives the appropriate treatment for his condition. As a result, John's health insurance provider covers the cost of the knee replacement surgery, which helps to control healthcare costs for both John and the insurance provider.

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