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Pre-certification Requirements

The pre-certification requirement helps ensure that hospital services and certain outpatient procedures and services are medically necessary prior to receiving treatment.

Pre-certification Process

Pre-certification starts with a telephone call to the Scripps Medical Plans Member Service Center at (877) 552-7247 before you receive certain types of care. If you use a network provider, your provider will often make this call for you. The Plan makes pre-certification decisions based on your physician’s recommendations and the recommendations of nationally recognized medical guidelines that apply to certain procedures and services. Check with your provider or call the Scripps Medical Plans Member Service Center before receiving services to make sure that your care has been precertified within the time frames outlined below. Failure to follow these guidelines may result in a reduction in benefits.

Typically your physician will contact the Plan to obtain pre-certification but you are ultimately responsible for ensuring that the pre-certification process is followed.

If You Don't Pre-Certify

If you don't call when required, a penalty may be applied to your covered charges.

Penalty - If pre-certification is not obtained per procedure or service:
EPO - $250 penalty

When to Pre-Certify

Inpatient
Emergency admission: within 48 hours of admission or as soon as reasonably possible
Urgent admission: before you are scheduled to be admitted
Other admissions: at least 14 calendar days prior to admission

Outpatient
Emergency care: as soon as reasonably possible
Non-emergency care: at least 14 calendar days prior to admission or as soon as reasonably possible

Important Notice

Please remind your provider to obtain pre-certification for the services and procedures listed below. Failure to obtain pre-certification may result in reduced benefits or a financial penalty. Pre-certification for all inpatient care is required even if Scripps is not the primary payer.

If you’re not sure whether a service or procedure must be pre-certified, call the Scripps Medical Plans Member Service Center at 1-877-552-7247.

 

A Scripps Medical Plans Member Service Center representative will notify you, your physician and the facility about your pre-certified length of stay. If your physician recommends that your stay be extended, additional days must be certified. You, your physician or the facility will need to call Scripps Medical Plans Member Service Center at the number on your ID card no later than the final authorized day. The Plan will review and process the request for an extended stay. You and your physician will receive a copy of this letter.

Procedures Requiring Pre-Certification

The following services require pre-certification under all Plan options:

Type of Service

Inpatient Care

Hospital
- Surgical
- Non-surgical

Hospice facility

Organ and tissue transplants

Rehabilitation facility

Skilled nursing facility

Mental Health and Chemical
Dependency Care
- Hospital
- Treatment facility
- Partial hospitalization
- Residential treatment center

Other Services and / or Treatments Requiring Pre-Certification

  1. Artificial intervertebral disc surgery
  2. Mommies 2 B Maternity Program, including antenatal testing, perinatal consultations and counseling
  3. Bone Density, under age 60
  4. BRCA and genetic testing
  5. Conditionally eligible services
    • Alpha 1-proteinase inhibitor – human
    • Arthroplasty (Hip/Knee)
    • Botox injections
    • Cochlear devices and/or implantation
    • Cognitive skills development
    • GI tract imaging through capsule endoscopy
    • HeartFlow (FFRCT)
    • High frequency chest wall oscillation generator system
    • Hyperbaric oxygen therapy
    • Hysterectomy
    • Negative pressure wound therapy pump
    • Onco Type DX
    • Osseointegrated implant
    • Osteochondral allograft, knee
    • Percutaneous implant of neuroelectrode array, epidural
    • Somatosensory evoked potential studies
    • Stereotactic radiosurgery
  6. Dental implants for Osteonecrosis of the Jaw and oral appliances
  7. Diabetic equipment
    • Insulin pumps
    • Continuous glucose monitor
  8. Durable medical equipment
    • Customized braces
    • Electric or motorized wheelchairs and scooters
    • Limb prosthetics
    • Orthotic appliances not related to podiatric foot orthotics
    • INR (International Normalized Ratio) pump
  9. Educational Classes (asthma, diabetes and pregnancy) after the initial 6 visits
  10. Elective (non-emergency) transportation by ambulance or medical van, and all transfers via air ambulance
  11. Home health care services, including home uterine monitoring and psychiatric home care services
  12. Infertility surgical services
  13. Medical-surgical inpatient care (all), including:
    • Surgical and non-surgical hospital confinements
    • Skilled nursing facility care
    • Rehabilitation facility confinements
    • Hospice
  14. Medical injectables/infusion
    • Blood-clotting factors
    • Chemotherapy
    • Erythropoiesis stimulating agents (ESA) such as darbepoetin alpha (Aranesp), epoetin alpha (Epogen and Procrit) and epoetin beta (Micera)
    • Growth hormone
    • Hyaluronic acid injections
    • Interferons when used for hepatitis C
    • Intravenous immunoglobulin (IVIG
    • Iron infusion/injection drugs
    • Synagis
    • Xolair
  15. Mental health and chemical dependency services – all inpatient care
  16. Nutritional counseling after the initial 6 visits
  17. Organ and tissue transplants
  18. Orthognathic (jaw) surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint
  19. Plasmapheresis
  20. Radiation Therapy
  21. Reconstructive procedures that may be considered cosmetic:
    • Blepharoplasty, canthopexy, canthoplasty
    • Breast reconstruction, breast enlargement
    • Breast reduction, mammoplasty
    • Excision of excess skin due to weight loss
    • Gastroplasty, gastric bypass
    • Lipectomy, removal of excess fat
    • Pectus excavatum repair
    • Rhinoplasty, rhytidectomy
    • Sclerotherapy, surgery for varicose veins
    • Skin laser therapy
    • Surgical treatment of gynecomastia
  22. Rehabilitation Services
    • Speech Therapy
    • Brain Rehabilitation Programs
  23. Other outpatient therapies after 24 combined visits
    • Physical therapy
    • Occupational therapy
  24. Spinal fusion surgery
  25. Uvulopalatopharyngoplasty, including laser-assisted procedures
**Important Notice** Please remind your provider to obtain pre-certification for the services and procedures listed above. Failure to obtain pre-certification will result in reduced benefits or a financial penalty. Pre-certification is required even if Scripps is not the primary payer. If you’re not sure whether a service or procedure must be precertified, call the Scripps Medical Plans Member Service Center at 1-877-552-7247.