Authorization, Pre-Certification, Pre-Determination and Gap Exception Meanings and Definitions

 

1. Pre-Authorization /Pre-Certification is a decision by your medical health insurance or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary or covered. Sometimes called prior authorization, prior approval, or precertification.  

• Meaning- A pre-authorization requirement means that the insurance company will not pay for a service unless the provider (a physician) gets permission to provide the service.  

• Meaning- A pre-certification requirement means that a payer must review the medical necessity of a proposed service and provide a certification number before a claim will be processed and paid.   

2. Pre-Determination - is for benefits of your medical health insurance plan is a process through which your insurance medical staff reviews the recommended treatment. ... This is typically done before you receive the service, which gives you enough time to see if the procedure is covered by your medical health plan. Before moving forward with treatment.   

• Meaning- redetermination relays the specifics of coverage after preauthorization is complete. A patient’s predetermination from the insurance provider will include necessary information, including what percentage of coverage is available, how the insurer will pay the claim, and when you or your patient will receive repayment. Additionally, predeterminations will usually include information regarding whether your patient will receive in-network coverage from the insurer for oral appliance therapy in your office

3. Gap Exception- Is when your medical health insurance grants you a network gap exception, also known as a network deficiency, gap waiver, in-for-out, clinical gap exception etc., it's allowing you to get receive treatment from an out-of-network provider at a cost share of a in network provider. 

• Meaning- once a gap exception has been approved for a specific services claim will be paid at in network level on a case-to-case basis.