A Pre-certification or Predetermination Tool is used by the provider to submit clinical information for an authorization request (precert or predetermination). If a provider uses this tool, chart records and letters of medical necessity will not be needed unless the tool is selected for auditing.
The Clinical Data Submission Tools on this site may be used to submit clinical information for either a pre-service review (pre-certification or pre-determination) or Post Service review, including pre or post claim submission.
For a list of services requiring prior approval as per the Member’s Service Benefit plan, click
HERE. The Federal Employee Program also offers optional Advanced Benefit Determinations for guarantee of payment for other services. Information on this process may also be accessed using the link above.
Some of the links on this page can only be viewed using Adobe Acrobat Reader. If you don't have Adobe Acrobat Reader, you can download a free copy by clicking
HERE.
