For certain medical procedures, your health insurance company might require a pre-determination letter from your medical provider. Before performing that particular procedure, your doctor must receive confirmation that it is covered under your health insurance plan and approved by the insurer.
Your health insurance company should have a pre-determination form available on its website for your doctor's staff to download. Information required on the form includes not only your personal information, but also that of your health-care provider and the anticipated date of the procedure. Your doctor fills out a service description based on diagnostic codes, then adds pertinent information in writing. Once all necessary information is received, the medical review staff at your insurance company decides whether the requested service is appropriate for your treatment needs.
Along with the pre-determination form, your doctor must submit various documents to the insurance company. These include information regarding previous treatments for the condition and your response; a list of medications prescribed for the condition; all symptoms and a history of their onset; and the results of any tests. Test results might include X-rays, magnetic resonance imaging (MRI) scans and any diagnostic procedures. Any other relevant reports and evaluations must also be included.
Relevant Procedures and Services
Certain services and procedures often require a pre-determination letter, although they can differ depending on your health insurance provider. The Blue Cross and Blue Shield of Illinois website lists services that generally require the pre-determination letter. These include dental implants, breast reduction, Botox treatments, nasal surgery, growth hormone treatment, breast MRIs, chelation therapy, positron emission tomography (PET) scans, intravenous immunoglobulin (IVIG) treatment, liposuction, osteotomy -- surgery to relieve arthritis symptoms -- and varicose vein surgery.
Different Types of Letters
Although they're easily confused, a pre-determination letter is not the same thing as a pre-certification or pre-authorization letter. A pre-certification letter requires you, not your medical provider, to notify your health insurance company before undergoing a procedure. When you receive certification, your insurance company should assign a certification number. A pre-authorization letter is verification by your health care provider that proposed treatment is covered by your plan. If you have questions, contact your health insurance provider via the 800-number listed on your health insurance card or the insurer's website.
A graduate of New York University, Jane Meggitt's work has appeared in dozens of publications, including Sapling, Zack's, Financial Advisor, nj.com, LegalZoom and The Nest.