Precertification is the process of obtaining approval from an insurance company for you
to have an exam. If we do not receive precertification from your insurance company for your
exam, your insurance company may not pay for it, leaving you responsible for the entire cost
of the exam. It’s important to note that when your insurance company precertifies an exam,
it is not a guarantee of payment until the claim is received and meets clinical guidelines.
Some exams, such as mammograms, do not require precertification with the insurance company.
Additionally, some insurance companies do not require precertification for any exam. Exams
such as MRI, CT, biopsies, and pain management are generally precertified. Following is
information about the precertification process for non-emergency exams.
In order to have your exam or procedure precertified, we must receive the following
documentation. Most of this will be provided by the physician ordering your exam.
However, we may need to contact you for some it.
- Verbal or written order from the referring physician
- Insurance information including the policy number, group number, and the name of the insurance company
- Detailed diagnosis, detailed clinical indications, past medical history, and the reason for the
- Referral from your primary care physician to the physician ordering the exam, if applicable and
if the insurance company requires it
Once this information is obtained, we will contact your insurance company for approval.
Please note that some insurance companies require the referring physician to initiate the
precertification process. Our goal is to have the precertification completed within 72 hours.
Common Causes for Delays in Precertification
Delays can occur in the precertification process due to the following circumstances:
- Incomplete orders
- Expired insurance policy
- Medical information does not meet the precertification criteria for the insurance company
- A Peer to Peer medical review is required
- Correspondence with the referring physician is needed
Please note that a precertification is not a guarantee of payment until the claim is received
and meets clinical guidelines.
Our staff has core knowledge of the ever changing precertification guidelines. Please feel free
to contact us at 303-643-4603 if we can answer any of your questions. Our hours are 8:00am - 5:00pm, Monday - Friday.