Precertification is an administrative process in which a healthcare provider submits a treatment plan on behalf of a patient to an insurance company before starting treatment to ensure the insurance company will cover the plan as submitted. This administrative process is frequently handled by experienced nurses, who are usually registered nurses, but licensed practical nurses are occasionally hired as well. To complete this process, a precertification nurse will perform a variety of tasks. Patient admissions and discharges are processed, patients are registered, insurance is verified, all documentation is available and in order, treatment plans are submitted to insurance companies, and the appeals process is handled when care is denied. When necessary, the responsibility also includes communicating changes to insurance programs and contracts.
Before administering or dispensing to a patient, insurance companies frequently require precertification of certain treatments and medications. Medical providers must be aware of which procedures and medications require precertification and obtain authorization prior to administering treatment. Precertification nurses will spend the majority of their time filling out paperwork, researching information online and in print, entering required data, and communicating with healthcare providers, insurance companies, and patients. End-of-month reconciliation between his or her patient’s accounts and insurance companies may be performed by the precertification nurse.
A precertification nurse will collect all required medical data from the patient’s attending medical professionals, as well as the necessary information about insurance coverage from the patient. After that, he or she will assign procedure codes to all recommended treatment plans. The precertification nurse will document all diagnostic procedures and ensure accuracy before submitting to insurance companies, using Current Procedural Technology (CPT) and International Classification of Diseases Book 9 (ICD-9) codes. He or she will then determine which precertifications are required, complete and process the necessary precertification paperwork, and submit it to the insurance company for approval. He or she will inform the attending medical professionals as well as the patient once the request has been approved.
If a treatment plan is denied, the precertification nurse will usually start the appeals process and oversee it until it is completed. To ensure that patient medical records are up to date and reflect the outcome of the precertification process, coordination with the medical records staff is frequently required. In addition, the job may entail applying payments from insurance companies to the correct patient accounts. Other responsibilities include prioritizing caseloads, recognizing urgent cases, and processing cases quickly and efficiently while adhering to the healthcare provider’s protocols.