Pre-Admission Certification Clause Samples
The Pre-Admission Certification clause requires that a patient or their healthcare provider obtain approval from the insurer before being admitted to a hospital for certain non-emergency procedures. Typically, this involves submitting relevant medical information to the insurer, who then reviews the necessity and appropriateness of the proposed hospitalization. By mandating this pre-approval process, the clause helps control healthcare costs and ensures that only medically necessary admissions are covered, thereby reducing unnecessary hospital stays and potential insurance disputes.
Pre-Admission Certification. If an employee or a dependent is informed that a non-emergency inpatient admission is necessary, including psychiatric/substance abuse treatment, the admission must be pre-certified by the City's Medical Utilization Review Administrator. If no pre-certification is made, a ten percent (10%) penalty will be applied to total charges in addition to the deductible, coinsurance, and out-of-pocket maximum provisions. In the event the care is determined to be medically unnecessary, the employee will be responsible for all charges for medically unnecessary care.
Pre-Admission Certification. If a member or a dependent is informed that a non-emergency inpatient admission or inpatient psychiatric treatment is necessary, the admission must be pre-certified by the City's medical utilization review administrator. If no pre-certification was made, a ten percent (10%) co- insurance will be applied, in addition to the deductible and co- insurance provisions. This ten percent (10%) co-insurance does not apply to the out-of-pocket maximum. If the hospitalization is determined not to be medically necessary, the member will be responsible for the cost of all medically unnecessary care. If using a PPO network provider, the provider will be responsible for pre-certification. The member is responsible for pre- certification if a non-participating provider is used.
Pre-Admission Certification. Under the Pre-Admission Certification/Concurrent Review Program, the doctor's recommendation for non-emergency hospitalization is reviewed and "pre-certified" before the individual is admitted to the hospital. Any elective non-emergency hospital stay (including maternity admissions) must be pre-certified. Failure to follow the pre- admission procedure may result in the patient paying the first two hundred dollars ($200) of room and board charges. The admission procedure must be followed for emergency care within forty-eight (48) hours after the emergency. The Board shall purchase through a carrier licensed by the State of Ohio, employee and family Vision Insurance equal to or exceeding the specifications below. The full cost of this program and any increases thereof shall be paid by the Board.
Pre-Admission Certification. Under the Pre-Admission Certification Concurrent Review Program, the doctor's recommendation for non-emergency hospitalization is reviewed and "pre-certified" before the individual is admitted to the hospital. Any elective non-emergency hospital stay (including maternity admissions) must be pre- certified. Failure to follow the pre-admission procedure may result in the patient paying the first two hundred dollars ($200) of room and board charges. The admission procedure must be followed by emergency care within forty- eight (48) hours after the emergency.
Pre-Admission Certification. If an employee is informed that a non-emergency inpatient admission is necessary, including psychiatric/substance abuse treatment, the inpatient admission must be pre-certified by the City's medical utilization review administrator. If no pre-certification is made or the inpatient admission is determined not to be medically necessary, a ten percent (10%) penalty will be applied to total charges in addition to the deductible, coinsurance and out of pocket maximum. In the event the care is determined to be medically unnecessary, the employee will be responsible for the cost of all medically unnecessary care. Emergency Admissions. Emergency inpatient hospital confinements including inpatient psychiatric treatment must be certified within forty-eight (48) hours of admission, unless the employee is incapable of communicating with the City due to his/her medical or psychological conditions, or a ten percent (10%) penalty will be applied to total charges in addition to the deductible, co-insurance and out-of-pocket maximum. In the event the care is determined to be medically unnecessary, the employee will be responsible for the cost of all medically unnecessary care.