Penalties for late pre-certification update

In the October 2017 edition of Network Update, we shared information regarding the application of monetary penalties, such as a reduction in payment, for failure to comply with the pre-certification requirements of the Utilization Management Program. The notice indicated that we require pre-certification prior to certain elective services in both the inpatient and outpatient settings. For an emergency admission, pre-certification is not required; however, you must notify us of the admission within the timeframe specified in the Provider Manual or as otherwise required by law. Failure to comply with these requirements can result in reimbursement penalties for commercial claims. For clarification, the reimbursement penalties may be 30% or 100%, which means the claim may be denied in full. Providers and facilities may not balance bill the member for any such reduction in payment.

 

For more information about the Utilization Management Program, please see the Provider Manual located on our provider website.