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Cigna Pre Determination Vs Pre Certification

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Started by Nikki613, Jun 26, 2012 1:04 PM
2 replies to this topic
2 replies to this topic

    Nikki613

    Guru in Training

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Posted June 26, 2012 - 1:04 PM

#1
i am so confused. whats the difference? apparently my paperwork was in the determinatiin queue and should have ben in the certification? idk someine kniw the difference????


    Wheetsin

    Token Atheist

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Posted June 26, 2012 - 1:12 PM

#2
Preauth is most likely where you want to be.

Predetermination is really just a determination of whether or not you're eligible (i.e. does your plan cover it IF all conditions are met). Predetermination is optional, say if your provider wants more info on what's required or coverages. Preauthorization virtually always has to be done in order for your benefits to be payable. It's also a more of the big picture, like "I've done this, and these things are true, and here's this documentation - am I eligible?"

Does that help?

Here's a little more clarification:

The Pre-certification Process:

  • Facilitates communication with the treating practitioner and/or member in advance of the procedure, service or supply.
  • Enables the health plan to proactively identify patients who may require continued disease management.
Preauthorization is the process used to confirm whether a proposed service or procedure is:
  • Medically necessary.
  • Covered for the proposed care.
  • Covered for the proposed length of stay (if applicable).
  • Scheduled for concurrent review.




    IMSKINNY

    Junior Guru

  • Posts: 389
  • Joined: Mar 2012
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Posted June 26, 2012 - 9:03 PM

#3

Preauth is most likely where you want to be.

Predetermination is really just a determination of whether or not you're eligible (i.e. does your plan cover it IF all conditions are met). Predetermination is optional, say if your provider wants more info on what's required or coverages. Preauthorization virtually always has to be done in order for your benefits to be payable. It's also a more of the big picture, like "I've done this, and these things are true, and here's this documentation - am I eligible?"

Does that help?

Here's a little more clarification:


Where'd you get your definitions from? Is there a definition for what actually happens during a medical review?


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