Have you ever been in this situation? Your doctor says you need a test or procedure, but it must be approved by your health insurance company first. The news of needing services alone may cause some anxiety, but the thought that you might have to go through a process to get it approved beforehand may cause you to break out in a full-blown sweat.
But, it doesn’t have to be that way. Just by understanding a little more about pre-service review Opens New Window can help calm your nerves. And, the good news is — as long as you choose and use an in-network doctor, all that approval work will be done for you.
What is a pre-service review and why is it needed?
A pre-service review is an authorization that must be done in partnership with your doctor and health insurance company before certain services, procedures and tests can be done.
While your doctor's expertise and recommendations are extremely important to your treatment plan, your health insurance company has a complete view of your health and history. Pre-service reviews help your doctor and health insurance company come together to make sure your care is appropriate, timely and safe.
They also help avoid any unexpected medical bills that might happen if a procedure or service isn't covered. Plus, pre-service review helps our team here at Wellmark Blue Cross and Blue Shield provide support throughout your experience, if needed.
I’ve heard a lot of terms associated with pre-service review. What’s the difference between all of them?
Here’s a rundown of the most common types of authorizations:
- Prior approval determines whether a proposed treatment is medically necessary. For example, a heart transplant or knee replacement surgery.
- Notification is required before you’re admitted to a hospital, excluding emergency and maternity services.
- Precertification determines medical necessity for certain types of admissions, like to a skilled nursing facility.
- Prior authorization is specific to certain prescription drugs and drug-related treatments Opens New Window.
- Preauthorization is needed for radiology services, like a Magnetic Resonance Imaging (MRI) or Positron Emission Tomography (PET) scan, done in an outpatient setting.
- Out-of-network referral is necessary when your treatment requires out-of-network care.
What types of treatment require pre-service review?
Each type of authorization has a comprehensive list of procedures, services or admissions that require pre-service review Opens New Window. If you have health insurance through an employer, it’s important to log in to myWellmark® Opens New Window to check your specific benefits and pre-service review requirements.
Am I responsible for doing pre-service review for certain services and procedures?
As long as you choose and use a doctor who participates in your network, he or she is responsible for knowing whether or not pre-service review applies to your treatment. It’s best to always ask your doctor to make sure any necessary requirements have been taken care of before you’re treated.
Out-of-network doctors aren’t required to handle authorizations on your behalf.
About how long does a typical pre-service review take?
In general, pre-service reviews take around 15 calendar days. However, if the request is urgent, it may be handled in as little as 24 hours for Wellmark members in South Dakota and 72 hours for members in Iowa.
What happens if a pre-service review isn’t completed for a service that requires it?
If you or your doctor doesn’t complete an authorization when it’s required, you may have to pay more for your service, or even the entire bill.
Where can I go if I have questions about pre-service review?
If you’re a Wellmark member, we’re here to answer your authorization questions. Always check your benefits before receiving services. To quickly and easily access your coverage manual 24/7, log in to myWellmark Opens New Window.