Precertification

​​Precertification means that a particular healthcare service must be reviewed and approved in advance to be covered by the Medical Plan.

Precertification helps ensure that services and tests are medically necessary and appropriate. Most tests, procedures, and admissions that require precertification are listed on the back of your medical ID card. These include the following services:

  • hospital admissions for nonemergency medical or surgical treatment
  • bariatric procedures, including gastric bypass
  • scheduled outpatient imaging, excluding X-rays
  • cardiac imaging, including scheduled nuclear stress tests
  • all facility-based treatment for behavioral health or substance use disorders
  • prescriptions for medical injectable drugs

Allow up to 10 days for precertification of a non-emergency service.

If precertification has been requested, you may receive a letter approving or denying the procedure from eviCore, a medical benefits management company that works with Highmark to provide support for precertification of outpatient imaging.

In many instances, your provider’s office will coordinate the precertification process for you. However, it’s your responsibility to verify that precertification has been obtained. If you are unsure whether a test or procedure needs advance approval, call the number on the back of your medical ID card or the Board of Pensions at 800-773-7752 (800-PRESPLAN) before having it performed.

Emergency hospital admissions

All emergency hospitalizations, whether for medical or surgical treatment, behavioral health, or substance use disorders, must be precertified within 48 hours of admission. Benefits are payable only if precertification requirements are met.

If you do not precertify

The precertification process helps to manage costs for members and the plan by ensuring care is medically necessary and appropriate. If you fail to precertify services when required, benefits may be denied.

Outpatient therapy for behavioral health and substance use disorders

You are encouraged to contact your service provider at the number on the back of your medical ID card before beginning outpatient treatment with a therapist, but you're not required to precertify this care. Your service provider can help match you with a provider who has the appropriate background and experience to address your concerns.