The precertification process helps guide you to the right care. With the introduction of care navigation effective April 1, 2022, Quantum Health will handle all precertification of medical services for PPO, EPO, and HDHP members when required. During the precertification process, Quantum Health's Care Coordinators work with you and your healthcare providers to help you get the best possible care.
Precertification means that a healthcare 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 on or after April 1, your healthcare provider should call Quantum Health to precertify the care. Your Quantum Health Care Coordinators will work directly with the provider to obtain the necessary documentation. The precertification process is typically completed within two business days after Quantum Health receives all the information needed from your provider.
Note: To precertify care before April 1, 2022, you or your healthcare provider should continue to call Highmark at 888-835-2959.
Be sure to share the new medical ID card you receive in March with your healthcare provider. The back of your new card includes the toll-free number for your provider to precertify care through Quantum Health, along with the services that must be precertified.
Blue Cross Blue Shield network providers typically handle the precertification process on your behalf, but it's your responsibility to make sure precertification has been obtained. If you have a medical test or procedure coming up, contact Quantum Health at the number on the back of your new medical ID card and your Care Coordinator will
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 precertification requirements are met.
The precertification process helps ensure care is medically necessary and appropriate. If you fail to precertify services when required, benefits may be denied.