Precertification helps ensure the right care in the right setting

August 25, 2021

​Precertifying medical services in advance helps things go smoothly when you or a covered family member need certain types of care or treatment.

If you have a scheduled hospital stay or test coming up, keep in mind that your care may require precertification. Precertification means that a medical treatment or test has been pre-approved as medically necessary and appropriate.

If you are enrolled in the PPO, EPO, or HDHP, the back of your medical ID card shows a list of services that require precertification.* These include non-emergency hospital admissions and certain diagnostic tests, such as MRIs and PET scans for example. Network providers will handle the precertification process on your behalf but it's your responsibility to make sure it gets done. If you aren't sure whether a specific test or procedure must be precertified, call Highmark Blue Cross Blue Shield at the number on the back of your ID card.

If a treatment or procedure requires precertification and you have it done without getting it precertified, you could face significant out-of-pocket costs. While your provider may be able to get approval retroactively in some situations, benefits could be denied. In that case you would be responsible for the entire cost.

Read more about the Medical Plan's precertification requirements. And when planning for a hospitalization or medical procedure, always double-check that your provider has contacted Highmark to precertify your care as required. 

*Those enrolled in Triple-S or GeoBlue should consult their plan's provisions for information on any precertification requirements. Those in the Medicare Supplement Plan should consult the Medicare & You handbook or visit medicare.gov. Traditional Medicare typically does not require precertification except in limited circumstances.