Precertifying care
The precertification process helps guide PPO, EPO, and HDHP members to the right care.
Precertification is handled by either Quantum Health or Highmark Blue Cross Blue Shield (BCBS), depending on the type of service:
- As part of care navigation, Quantum Health handles all precertification of medical services when required.
- Highmark BCBS handles precertification as required for behavioral (mental health and substance use disorder) health services.
During the precertification process, a Quantum Health Care Coordinator or Highmark BCBS representative will work with you and your providers to help you get the best possible care.
Why precertification is important
Precertification means that a service must be reviewed and approved in advance to be covered by the Medical Plan. The precertification process helps to ensure you receive high-quality, safe, and effective care in the appropriate setting.
If you or a covered family member needs to have any of the following services, your provider should call either Quantum Health or Highmark BCBS, as noted, to precertify the care. Depending on the request, a Quantum Health Care Coordinator or Highmark BCBS representative may contact your provider to obtain the necessary documentation. The precertification process is typically completed within two business days after all the information needed from your provider is received.
Medical services requiring precertification with Quantum Health:
- inpatient and skilled nursing facility admissions
- outpatient surgeries
- MRI/MRA/PET scans
- oncology care and services
- genetic testing
- dialysis
- transplants
- home health care
- hospice care
- durable medical equipment (all rentals and purchases over $1,500)
Behavioral health (mental health and substance use disorders) services requiring precertification with Highmark BCBS:
- inpatient admissions
- applied behavior analysis therapy
- partial hospitalization and intensive outpatient care
What you need to do
Here's just one story, shared by a patient's employer, that shows how Quantum Health's Care Coordinators work to make sure individuals are using their benefits in the best way possible. The patient's doctor called Quantum Health to precertify an MRI, and the Care Coordinator realized the doctor was sending them to an out-of-network facility. Quantum Health reached out to the patient with a heads up that this would cost them more out of pocket. The Care Coordinator even helped them get an appointment that very day at a nearby network facility, saving them both time and money.
Be sure to share your medical ID card with your healthcare provider. The back of your card includes the toll-free number for your provider to precertify care through Quantum Health or Highmark BCBS, along with the services that must be precertified.
BCBS network providers typically handle the precertification process on your behalf, but it's your responsibility to make sure precertification has been obtained. If you are unsure whether a service requires precertification, contact Quantum Health at the number on the back of your medical ID card and a Care Coordinator will assist you.
Emergency hospital admissions
All emergency hospitalizations, whether for medical or surgical treatment, behavioral health, or substance use disorders, must be precertified within 48 hours of admission. Benefits are payable only if medically necessary.
If you do not precertify
The precertification process helps ensure care is medically necessary and appropriate. If you fail to precertify services when required, benefits may be denied.