Certification is a review process used to determine if certain services are medically necessary according to HealthChoice guidelines. Certification is performed by either the HealthChoice certification administrator or by the HealthChoice Health Care Management Unit (HCMU), depending on the type of services.
The provider must obtain certification under certain situations, including when the member or the member’s covered dependents:
- Are admitted to a hospital or are advised to enter a hospital;
- Require certain surgical procedures that are performed in an outpatient facility;
- Require certain diagnostic imaging procedures;
- Have an observation** stay that lasts longer than 24 hours; or
- Have HealthChoice as the second or third carrier.
Certification is required within three working days prior to scheduled hospital admissions, certain surgical procedures in an outpatient facility and certain diagnostic imaging procedures, or within one day following emergency/urgent services. To request certification, the provider must contact the certification administrator.
If certification is not initiated and approved within the time frames described above, but is approved after services are performed, and all other plan rules and guidelines are met, a 10% penalty is applied. The member is not responsible for this 10% penalty. If certification is denied because medical necessity guidelines are not met, either before or after services are performed, the claim is denied.
When using a non-Network provider, the member is responsible for paying the 10% penalty and for any services deemed not medically necessary according to HealthChoice guidelines.
Inpatient hospital services require certification through the certification administrator.
The following surgical procedures require certification through the certification administrator:
- Blepharoplasty - Correction to the eye lid
- Rhinoplasty - Reconstruction of the nose
- Breast implant removal - Removal of breast implants
- Scar revision - Removal of scar tissue
- Breast reduction - Reduction in breast size
- Panniculectomy - Reduction in abdomen size
- Surgical treatment of varicose veins
- Spinal cord stimulator (neurostimulator) placement
- Correction of lid retraction
Certification is required for all transplants.
- Bone marrow
- Peripheral stem cell
The following diagnostic imaging procedures require certification through the certification administrator:
- Sinus CT / MRI
- Head / Brain CT / MRI
- Chest CT including spiral CT (RAD)
- Spine CT / MRI
- Shoulder MRI
- PET scans
Other Services that Require Certification
Certain services require certification through the HealthChoice Health Care Management Unit. Providers must contact the HealthChoice Health Care Management Unit at 1-405-717-8879 or toll-free 1-800-543-6044, ext. 8879. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
- Non-emergency ground or air ambulance
- Home health care services
- Speech therapy for ages 17 and younger
- Physical medicine services
- Mental health outpatient services
- Chiropractic care
- Botox injections
- Durable medical equipment
- TMD treatment
- Oral surgery
This list is not all-inclusive.
The Network Provider and the member equally share the responsibility for obtaining certification for hospital admissions. EGID requires certification of all non-emergency hospital admissions at least three working days prior to the actual admission (this excludes maternity admissions for the delivery, which do not require certification). Emergency admissions require notification within 24 hours (one working day) of the actual admission date. Holiday or weekend admissions must be certified by the first working day following the date of hospital admission. The hospital, physician and member receive a letter verifying certification.
Upon initiation of the certification process, a reference number is assigned to the case (assignment of a reference number does not complete the certification process or guarantee benefits). Utilization review staff members review medical information pertaining to the patient. If initial requirements are met and the certification is approved, the 10% penalty is not assessed to the claim payment.
The certification administrator updates the progress of the patient at established intervals during the concurrent review process. The medical necessity of additional inpatient days is also determined during the concurrent review process. The certification administrator performs retrospective reviews/appeals. A retrospective review/appeal could be warranted in the following situations:
- Admission denials
- Surgical procedure denials
- Additional inpatient days denied
All hospital confinements billed as observation must be certified within one working day with the exception of observation stays that are less than 24 hours and without room and board charges**. When certification is not initiated and approved within the established time frame, but is approved retrospectively, and all other Plan rules and guidelines are met, the claim payment is assessed a 10% penalty. The member is not responsible for paying this 10% penalty.
Confinements billed as observation, in which room and board charges are incurred, are paid based on inpatient benefits if the stay is certified.
Claims submitted for certified inpatient hospital admissions with a duration of less than 24 hours are processed utilizing benefits for outpatient hospital services (unless room and board charges are incurred).
Effective April 1, 2015:
- Observation Stays of 47:59 Hours or Less
- Certification is not required;
- Charges must be billed as outpatient services; and
- Charges for a subsequent inpatient admission must be combined with charges for the observation stay and all charges must be billed as inpatient services.
- Observation Stays of 48:00 Hours or Longer:
- Observation stays that are longer than 48 hours are not covered; however, if charges for room and board are billed, certification is required by the certification administrator; and
- Charges for room and board must be billed as inpatient services.
- Observation Stays through the emergency room or for scheduled/not-scheduled outpatient surgery must be billed as outpatient services, unless charges for room and board are billed, then charges should be billed as inpatient services.