Review and approval process completed before hospital admission to ensure the medical necessity for the acute level of care and for the proposed services and procedures, to avoid a weekend admission, and to forecast the expected length of stay. The review process may include an assessment of the physician's proposed treatment protocol and fees. Compliance with changes in the treatment plan recommended by the reviewing entity may be a condition of receiving full coverage under the health benefit. The benefit level may be reduced or services not covered at all if the patient fails to comply with plan requirements. The pre-admission review process may also include an administrative confirmation of the patient's eligibility for benefits, covered services and restrictions, and the determination of applicable deductibles, co-payments, and maximums.
The practice of reviewing claims for hospital admission before the patient actually enters the hospital. This cost-control mechanism is intended to eliminate unnecessary hospital expenses by denying medically unnecessary admissions.
Review and approval for necessity and appropriateness of the care proposed for a patient prior to the patient's admission to a hospital or other health care facility. Under health plans where PAC is required, pre-admission certification is a prerequisite for payment.
can also be names pre-certification review, that means a medical case manager or certified health insurance associate must request admittance to a medical treatment facility, before being physically admitted to the facility. The health insurance policyholder usually assembles pre-admission certification documents. Physicians, Surgeons, or nurses may contact the patient. This avoids patients from early exposure to unnecessary health care treatment services.
Determines whether a hospital should admit a patient and whether services can be provided on an outpatient basis; its goal is to eliminate unnecessary nonemergency procedures.
An assessment, prior to elective inpatient hospital care, to determine whether the proposed health care services meets the medical necessity criteria for payment under a health plan. plan.
A component of utilization review under which the utilization review organization determines whether an insured's proposed non-emergency hospital stay or some other type of care is most appropriate and what the length of an approved hospital stay may be.
Also called pre-certification review, or pre-admission review. Approval by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-admission certification often must be obtained by the individual. Sometimes, however, physicians will contact the appropriate individual. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary).
Review by the insurance company before surgery to determine if the procedure is necessary and if it could be done on an outpatient basis. Most insurance companies will not cover surgical procedures without a pre-admission certification.
Also called pre-certification review, or pre-admission review. This is approval by a case manager or insurance company representative for a person to be admitted to a hospital or in-patient facility in advance of their admission. Usually, the patient's physician requests that this process be completed. The goal of pre-admission certification is to ensure that individuals are not hospitalized for unnecessary surgical procedures or services that are not medically necessary.
The process in which a health care professional evaluates an attending physician's request for a patient's admission to a hospital to evaluate whether or not inpatient care is necessary.
Before being admitted as an inpatient in a hospital, certain criteria are used to determine whether the inpatient care is necessary. (H)
a review of the need for inpatient hospital care, done prior to the actual admission. Established review criteria are used to determine the appropriateness of inpatient care
