Coverage policies describe if the insurance company will pay for a procedure or service. New services or procedures tend to be classified in coverage policies by insurance companies as “investigational.” Coverage for these new services or procedures may be considered or reviewed by a private insurance company on a case-by-case basis. The doctor may submit a pre-determination request on behalf of the patient to verify if the private insurance company will cover for the procedure or service.
You may have heard of a pre-authorization of benefits request. This is different from a pre-determination request. Pre-authorization of benefits is the process that allows doctors and other healthcare providers to determine if the patient is eligible for coverage for a proposed service or procedure. It is also the process of securing authorization from a payer for a specialist and/or referral for non-emergency healthcare service. Pre-authorization of benefits is a requirement under a health plan, but it does not guarantee reimbursement.
Pre-determination of benefits is similar to pre-authorization in that it allows services and procedures to be reviewed for medical necessity. Benefit coverage is pre-determined before services are rendered and any limitation under a plan may be addressed before the service or procedure. A pre-determination request is submitted to your insurance company by your doctor. This is part of the reimbursement process for new procedures or services. Submitting a request for pre-determination of benefits is a courtesy and does not guarantee reimbursement.
Medicare does not accept pre-determination requests. As such, patients typically have a procedure or service performed and then find out if Medicare will pay for it after the claim is submitted by the doctor or hospital. You most likely will be given an “advance beneficiary notice” form, informing you that if Medicare denies payment for the procedure or service, you will be personally responsible for full payment.