Pre-Authorization of Services:

What you need to know about your Insurance

Pre-Authorization, also referred to as Pre-Certification (or Notification if you are a State of Illinois PPO plan member), is sometimes required by your health plan to evaluate the necessity, appropriateness, and efficiency of hospitalizations, surgical procedures, and tests. Pre-authorization requires that the hospital admission, surgical procedure, or test be approved in advance.

Without pre-authorization being obtained, your health plan or insurer will not pay for certain tests or services or will reduce the amount it will pay causing you to pay more out-of-pocket. Some health plans may even impose an additional monetary penalty on you.

All health plan members are ultimately held responsible by their health plan or insurer for pre-authorization. However, since clinical information is often required to complete the pre-authorization process, some health plans require that your doctor initiate the pre-authorization process, while other health plans will allow you to initiate the process. The hospital is required to verify with either your health plan or doctor that the pre-authorization has been completed but the hospital cannot initiate or complete the pre-authorization for you or for your doctor.

Below is a list of common service that, as an in-network provider for health plans and networks listed, Ferrell Hospital has been informed require pre-authorization. This is only a partial list and it may be subject to change by the health plan without Ferrell Hospital’s knowledge.

To avoid having your claim denied or benefits reduced:

  • Read your health insurance policy, employee benefits handbook and/or summary plan description provided by your employer or health plan.
  • Follow any instructions listed on the back of your health plan ID card

Prior to your hospital admission, procedure or test call the number on the back of your health plan ID card and ask if the service you are scheduled for requires pre-authorization. Be prepared to supply the date of the scheduled service, name of hospital you hare having the service performed at and your doctor’s telephone number.

Health Alliance

QHCM

(Quincy Healthcare Management)

Sagamore/

Select Health

State of Illinois

UMWA Health & Retirement Funds

Blue Cross

First Health

GRN (Great Rivers Network)

Healthlink

PHCS (Private Healthcare Systems)

ProAmerica

Hospital Admission

X

X

X

X

X

 

These providers are unable to provide us with a list of services that require pre-authorization because requirements vary by plan, type & by employer group; please call the number on the back of your ID card to find out which service require pre-authorization.

Outpatient Surgical Procedure

A few procedures do - so contact Health Alliance

X

X

X

X

X-rays

X

MRI’s

X

X

X

X

X

MRA’s

X

X

X

X

X

CT Scans

X

X

X

X

X

PET Scans

X

X

X

X

X

Sleep Studies

X

X

X

X

Colonoscopy

X

X

X

X

X

Endoscopy

X

X

X

X

X

23 Hr. Observation

X

X

X

X

X

Inpatient Rehab (physical, occupational, speech therapies)

X

X

X

X

Outpatient Rehab (physical, occupational, speech therapies)

X

X

X

X

X