Question:
HELP will someone please explain the difference between pre-approval
and pre-determination. Told I need both before surgery. — postonch (posted on May 25, 2009)
May 25, 2009
Hi Cathy,
I dont know what the diff is between the two. I know that the Dr. (PC)
had to see me every month for weight loss. It ment we talked about it..he
asked if I was eating correctly, weighed me,recomended medication for
weightloss. My surgeon.. set up ALL the preliminary tests to be done.
Sleep study, cardiac, chest xray, a psychi eval. We had everything done so
that when my year (that is what my ins. wanted) I was all set to get my
auth. My surg. send in the request to the ins. and we had a approval
2weeks later! I believe the pre determination would be for a DR. to say
you need the surg..then work on the pre-reqs for surg. Are you useing a
Bariatric surg DR.? They will know what to do when.
Hope I was a little help.
— tootsie52
May 25, 2009
I think the pre-determination is to figure out if you really need the
surgury. I've been pre-approved for surgury(August 26) It will become
definite when the insurance company gets all the paper work from the
predetermination work of my pcp, surgeon, and anything else that I had to
do. I hope this helps.
— Kathleen W.
May 25, 2009
pre-apporoval is when the doctors office calls and finds out if you
procedure is covered under your insurance and the insurance company gives
them a pre-approval pending the required thing are completed.
— Katie D.
May 27, 2009
Hello,
PREDETERMINATION OF BENEFITS
The predetermination of benefits process allows the medical provider -- at
the consumer's request -- to send the insurance company a statement listing
a proposed treatment or test, or the proposed purchase of medical
equipment. Within a few weeks, the insurance company will generally respond
with a statement of the amount of reimbursement the company will usually
provide for that test, procedure, or equipment.
Pre-Approval
Some health insurers require pre-approval, also known as pre-certification,
for certain types of healthcare services, such as surgery or hospital
visits. This means that you or your doctor must contact your insurer to
obtain their approval prior to receiving care, or else the insurer may not
cover it. Not all services will require pre-approval, but if you are in
doubt, it's best to contact your insurance company in advance of obtaining
any type of health care.
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