Pre-Certification of Medical/Surgery Services

Pre-Certification Process

The medical benefit plan does require pre-certification of certain services. This program is designed as a cost containment measure through a company called AmeriBen to maximize the Plan benefits and reduce unnecessary hospitalizations, surgical procedures, diagnostic and other services. Failure to comply with the pre-certification requirements may result in a $300 penalty, or may disqualify coverage of the benefit. It is always up to you, and the physician you choose, to determine what services you need and who will provide your care, regardless of what this Plan will pay for. Once a pre-certification is received, it is valid for ninety (90) days.

IMPORTANT:  Pre-certification of a procedure does not guarantee benefits.  All benefit payments are determined by AmeriBen in accordance with the provisions of this Plan.

Pre-certification is required on the following:

  • Diagnostic tests and surgical procedures over one thousand dollars ($1,000)
  • All non-emergency Hospital admissions or admissions to any type of care facility
  • Maternity admissions that exceed forty-eight (48) hours (ninety-six [96] hours for Cesarean Section)
  • Occupational, Speech and Physical Therapy treatment programs
  • Psychological and neuropsychological testing

What is the procedure for obtaining pre-certification?

For all non-emergency procedures that require pre-certification, the Covered Person or his/her Physician must contact AmeriBen prior to the admission or in advance of the procedure. AmeriBen’s phone number is (800) 388-3193 and is also located on your ID card.  It is recommended that pre-cert is requested at least seventy-two (72) hours in advance.  AmeriBen will review the request for services and contact the Physician for any records or additional information necessary to thoroughly evaluate the need for services.   Benefit eligibility for the pre-certified procedures must be verified with AmeriBen prior to completing services.

For emergency procedures or hospital admissions, the Covered Person, his/her Physician, the hospital admissions clerk, or anyone associated with the Covered Person’s treatment, must notify AmeriBen by telephone within forty-eight (48) hours of the procedure or the  admission.