ASPIR'E SOLUTIONS

Pre-certification

A health plan's precertification (or prior authorization) process usually begins with a nurse employed by the health plan completing an initial review of the patient's clinical information, which is submitted by the practice, to make sure the requested service meets established guidelines. If it does, the nurse authorizes the request and the health plan will cover the service. If the service does not meet the guidelines, the nurse refers the case to the health plan's physician reviewer (usually the medical director or a physician consultant), who decides whether to approve or deny the request based on the information provided to the health plan. The physician reviewer may also "pend" the request and ask the physician for additional information before making a final decision.

The precertification process is one of the reasons physicians and patients are so dissatisfied with HMOs, which use this strategy more often than other managed care organizations in an effort to contain costs. The trade-off is that HMO premiums are usually lower than those of other managed care organizations that offer fewer restrictions (e.g., PPOs and POS plans). Although many health plans are finding less punitive ways to cut costs, such as using care coordination, some form of utilization management will always be used because it encourages both patients and physicians to make cost-effective decisions and abide by the plan's rules. Aspire's make sure that eligibilty and pre- certifcation are done prior to patient treatment.

Insurance Carrier	Pre-Certification Required
AETNA/US HEALTHCARE (USHC plans - HMO, QPOS, USAccess with alpha numeric membership # on ID card) CALL MEDSOLUTIONS @ 1-888-693-3211	Pre-Certs required for MRI, MRA, CT Scan, Pet Scan, Nuclear Cardiac Imaging -as of 6/1/02 Referrals needed for all cardiac echocardiograms venous, carotid & arterial ultrasounds.
AETNA PLANS (Elect Choice & Managed Choice with SS# as membership # on ID card)	No Pre-Cert or referrals are required for CTs or any MRIs, MRAs
CIGNA HMO (PCP name on card) & some PPO plans -call AIM to confirm precert CALL AIM @ 800-859-5288	Pre-Cert required for all MRI, MRA, CT Scan and Nuclear Cardiac Imaging.
CONNECTICARE (pre-cert# for each procedure) CALL NIA @ 877-607-2363
ANTHEM BCBS - All Plans except Blue Care Family Plan (Medicaid plan) CALL NIA @ 888-864-7237*
FIRSTCHOICE HEALTH PLANS OF CT WELLCARE CHOICE MEDICARE PLAN 866-579-8006 Fax 800-246-7983	Pre-Cert required for all MRI, MRA, CT Scan and Nuclear Cardiac Imaging. (MRI, MRA, CT only for Wellcare)
HEALTH NET HealthNet Medicare & Medicaid plans. A separate authorization # is required for each exam CALL NIA @ 888-642-4810	Pre-Cert required for all CT, MRI, MRA, Nuclear Cardiology, and for OB ultrasounds ( only for additional ultrasounds ordered after the first )
HEALTHNET - IBEW Local 90 Plan only with Group # starting with TH######	Does NOT require precerts for above services listed in HealthNet.
OXFORD HEALTH PLAN (HMO) Oxford Medicare Advantage Plan CALL CARECORE @ 877-773-2884 **Oxford pre-cert #s from CareCore (NYMI). The last 5 #s of the precert # match the procedure code	Pre-Certs required for MRI, MRA, CT, Nuclear Medicine Procedures, & Nuclear Cardiac Imaging. Pre-Cert required for 3rd OB Ultrasound per pregnancy. Referrals needed for all cardiac echocardiograms venous, carotid & arterial ultrasounds.
TRICARE - PRIME PLAN ONLY Call - 1-877-874-2273	Pre-Cert required MRI, MRA, Nuclear Medicine Procedures, Nuclear Cardiac Imaging
WORKER'S COMPENSATION - Date of Injury, claim number and employer name and address are required!	Need name & phone number of patient's workers comp. Carrier and employer name and address. Get private insurance information also.