Medical Insurance "PREDETERMINED" Going CRAZY!! Help Me Figure This Out!!!!!?

Question

My son needs a surgery and the insurance company says the only way they will cover any costs is if the doctor shows it is predetermined, the letter from the doctor says that this surgery is the only viable option. Is that predetermined? I have no clue how to prove "predetermined" and the insurance people that I have talked to don't seem to understand how I get "predetermined" This is crazy I just need someone to tell me what I need to get!!! Thanks for any help

Answer 1

Predetermined is an actual health insurance term. (Generally means the same thing as "preauthorization" - some companies just use different terminology.)

How do you obtain a predetermination? Your doctor needs to submit the medical documentation and get approval from the insurance company *before* the procedure is done. If your doctor is in your insurer's network, he should be familiar with how to go about obtaining predetermination on your son's behalf.

The insurer has a defined list of medical criteria under which that particular surgery can be approved. (And either you and/or your doctor should be able to obtain that criteria upon request.) Your doctor submits your son's records. If his circumstances clearly meet the criteria for approval, then medical review will give their authorization for your son to have the procedure done. If your son clearly doesn't meet the medical criteria, then medical review will deny the request. (You will have appeal rights, and the denial letter should spell those out for you.) If its unclear as to whether or not your son meets the criteria, they will request more information from the doctors before making a decision.

Be forewarned that if you go ahead and have the surgery without a predetermination (i.e. - prior authorization from the insurer), you may end up being liable for the entire cost. So, make sure you have that predetermination before you proceed.

Answer 2

What the insurance is probably asking for is a precertification or preauthorization. This basically means that the doctor needs to prove that the surgery is medically necessary and that other treatments are not an option - either because of past trial and failure or just not viable for his condition. Since surgical care is rather expensive (they have to pay for the pre-operative and post-operative care, the hospital facility, any testing, the anesthesia and anesthesiologist, the surgeon, AND any medications) they're not going to just give a blank check, they want them to jump thru hoops for it to make sure they're not just doing it for funsies.

Ask the doctor's office - specifically the surgeon's office (make sure you have a valid referral to the surgeon from his regular doctor - if your plan requires them) to call and precertifiy the procedure. The surgeon's office will give the exact procedures and what is needed and where's it's going to be done, and your son's regular doctor can be on deck to provide any supporting information. (Such as WHY he referred to the surgeon.)

Answer 3

what i would do is have the doctors office call your insurance carrier directly to state the type of service needed and the reason. most surgical procedures require prior authorization. that is typically the responsibility of the doctors office.
if it is "pre-determined" by the doctor that this is needed then he/she will need to state the case.
for example - if someone is going in for an inpatient hospitalization or surgery and there is not an authorization on system, the claim will deny. have the doctors office do the leg work.
also, you can go to your HR department at work and have them call their direct contact for you so they can try to explain exactly what is needed in laymans terms. when you call into customer service, they are trained on what they can and can not say so you can not always blame the person on the other end of the phone.

Answer 4

I"m wondering if "predetermined" is the word they're actually using? I'd call them up, and have them spell it. Unless you mean "preauthorized". And your doctor can pre-authorize it.

Maybe you got a flaky claims person. Wouldn't be the first time.

Answer 5

ask the people in Insurance company about their qualifications to ask for predetermination. Take their names and qualifications and tell them you are forwarding it to the your State Health Commissioner.

Answer 6

Rather than calling the insurance company call your state insurance commissioner. They should be listed in your local phone book in the "government section". They are able to define and determine what it means. Good luck to you and your son.