Precertification—sometimes called prior authorization—is a process that requires physicians and healthcare providers to obtain advanced approval from the Health Plan before delivering a specific service to the patient to qualify for payment coverage.
APWU Health Plan’s contract requires precertification for:
- Inpatient hospital stays
- Home nursing care
- Physical, speech, or occupational therapy services
- CAT/CT/MRI/PET scans
- Durable medical equipment
See section 3 of the postal brochure to determine if a service you are about to receive needs precertification or prior authorization.
Inpatient hospital stays
Unless a hospital stay takes place outside of the United States or Puerto Rico, or unless you have other insurance, including Medicare Part A as your primary health insurer, all inpatient hospital stays must be precertified.
If a hospital stay is not precertified, a $500 penalty will be assessed when the claim is paid.
Planned admission into the hospital must be precertified as least two business days prior to the admission to avoid the precertification penalty.
If you have an emergency admission or an unscheduled maternity admission, you must certify the stay within two business days of the admission, even if you have already been discharged.
For a maternity admission, the newborn’s stay does not have to be precertified unless the child stays in the hospital after the mother has been discharged. At the time of the mother’s discharge, the newborn’s stay becomes a separate admission.
Home nursing care and physical, speech, or occupational therapy
If these services are not preauthorized, the Health Plan may deny services, even if they are considered medically necessary and appropriate. These benefits are covered when prescribed by a doctor, and the doctor submits a treatment plan for the services.
CAT/CT/MRI/PET scans
Prior approval of these procedures is required. Failure to obtain required precertification can result in a $100 penalty and/or denial of the claim pending review. Have your provider call prior to delivering these procedures.