What is pre-admission certification?
Pre-admission certification – also called pre-certification review, or pre-admission review – refers to the fact that many health plans require a member to receive approval from the health plan before receiving non-emergency inpatient care. Pre-admission certification is a type of prior authorization specific to inpatient care, but many health plans require prior authorization for various outpatient services as well.
Ultimately, the patient is responsible for ensuring that any necessary pre-admission certification has been granted by their health plan, as the patient is responsible for any bills that aren't paid by the health plan. But as long as the hospital and the patient's doctor are in-network with the patient's health plan, they will typically handle the prior authorization process on behalf of the patient. But the patient should ensure that this has been taken care of before being admitted to the hospital, to avoid surprise medical bills after the fact.
The goal of pre-admission certification is to ensure that individuals are receiving high-quality, medically necessary care in the most efficient manner possible. Pre-admission certification, like all types of prior authorization, cannot be required by a health plan if the situation is an emergency.
