Pre-Certification Process

The medical benefit plan requires pre-certification of certain services. This program is designed as a cost containment measure through a company called American Health Group (AHG) to maximize the Plan benefits and reduce unnecessary hospitalizations, surgical procedures, diagnostic and other services. Failure to comply with the pre-certification requirements will result in a $300 penalty, or may disqualify the Covered Person for benefits. It is always up to you, and the physician you choose, to determine what services you need and who will provide your care, regardless of what this Plan will pay for. Once a pre-certification is received, it is valid for ninety (90) days.

IMPORTANT:  Pre-certification of a procedure does not guarantee benefits.  All benefit payments are determined by AmeriBen in accordance with the provisions of this Plan.

Pre-certification is required on the following:

  • All non-emergency Hospital admissions or admissions to any type of care facility
  • Maternity admissions that exceed forty-eight (48) hours (ninety-six [96] hours for Cesarean Section)
  • Behavioral therapy services for treatment of Autism Spectrum Disorder
  • Clinical trials that are conducted in relation to the prevention, detection, or treatment of cancer, or other life-threatening disease or condition
  • Dental services required for medical procedures
  • Injectable medications over $1,000 administered in a physician’s office or in conjunction with home health services
  • Organ, tissue, or bone marrow transplants and stem cell procedures
  • Orthognathic surgery
  • Advanced imaging
  • Sleep studies
  • Rehabilitation services in excess of 20 visits
  • Requests for services by a non-network provider for network cost share amounts

What is the procedure for obtaining pre-certification?

For all non-emergency procedures that require pre-certification, the Covered Person or his/her Physician must contact American Health Group prior to the admission or in advance of the procedure. American Health Group’s phone number is (800) 847-7605 and is also located on your ID card.  It is recommended that pre-cert is requested at least seventy-two (72) hours in advance.  American Health Group will review the request for services and contact the Physician for any records or additional information necessary to thoroughly evaluate the need for services.

For emergency procedures or hospital admissions, the Covered Person, his/her Physician, the hospital admissions clerk, or anyone associated with the Covered Person’s treatment, must notify AHG by telephone within forty-eight (48) hours of the procedure or the  admission.