Difrence btwn pre-certification, prior auth & determination of bnfts
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Question / Problem
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What is the difrence btwn pre-certification, prior auth & determination of bnfts ?
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Solution
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Pre-certification means the plan said, “Yes, you can do that specific procedure.” This does not guarantee
payment.
Prior authorization means the plan said, “You will be paid for this specific procedure.” Typically prior
authorization is requested, and provided, in writing. Written prior authorization from the payor is a
guarantee for reimbursement.
Determination of benefits means you’ve confirmed with the payor that the patient’s specific insurance
benefits available. This is not a guarantee of payment for a specific procedure.
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Applies to |
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Medical Billing
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