Pre-Certification
The medical benefit plan requires pre-certification of certain services. This program is designed as a cost containment measure through AmeriBen to maximize the Plan benefits and reduce unnecessary hospitalizations, surgical procedures, diagnostic and other services. Failure to comply with the pre-certification requirements will result in a $300 penalty, or may disqualify the Covered Person for benefits. 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.
Precertification is required for the following services:
- Inpatient admissions (surgical and non-surgical excluding routine newborn deliveries, longterm acute care, skilled nursing/rehabilitation facility, inpatient substance abuse/mental
disorder treatments including residential facilities); - Maternity admissions that exceed forty-eight (48) hours (ninety-six [96] hours for Cesarean
Section); - Outpatient surgical procedures (excluding outpatient office surgical procedures and screening
colonoscopies); - Advanced imagine (CT studies, Coronary CT angiography, MRI/MRA, nuclear cardiology,
nuclear medicine and PET scans excluding services rendered in an ER setting); - Outpatient rehabilitation services (physical, occupational and speech therapy) in excess of
twenty (20) visits per plan year; - Chemotherapy drugs/infusions and radiation treatments for oncology diagnoses;
- Home health care services and supplies;
- Transplants, including, but not limited to, kidney, liver, heart, lung and pancreas, and bone
marrow replacement to stem cell transfer after high dose chemotherapy; - Orthotics/Prosthetics over one thousand dollars ($1,000);
- Durable Medical Equipment over one thousand dollars ($1,000);
- Genetic testing/genomic testing (excluding amniocentesis);
- Clinical trials that are conducted in relation to the prevention, detection, or treatment of cancer
or other life-threatening diseases or conditions; - Specialty infusion/injectable medications provided in an outpatient facility, physician’s office
or home infusion over one thousand dollars ($1,000); - Behavioral therapy services for treatment of autism spectrum disorder; and
- Dental services required for medical procedures.
PLEASE REFER TO THE SUMMARY PLAN DOCUMENT FOR A CURRENT LIST OF SERVICES THAT REQUIRE PRE-CERTIFICATION!
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 at 855.778.9053. 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.