A Guide to Precertifications

How to pre-certify a medical procedure with an insurance provider abroad.

All international insurers require certain medical events to be precertified. Those include, but are not limited to:

• Hospitalization due to an emergency (if possible, see note below) or a planned future medical event

• Any type of surgery with general anesthesia

• All diagnostic testing, ie. MRI, Cat Scan, Pet Scan, etc.

• All cardiac procedures

• Radiotherapy and chemotherapy

• Palliative care and hospice

• Air ambulance

• Ambulatory therapies

• Home health care

• Durable medical equipment

• Organ and tissue transplant

• Repatriation of mortal remains

If you do not precertify for any of these events, you will face a penalty fee from your insurer.

The main goals of a precertification are:

• To notify the insurance provider of a future medical event or emergency.

• To have the insurance provider verify that the procedure or treatment will be covered under your benefits, and won't be excluded.

• If applicable, to set up a direct pay arrangement with the hospital to pay them directly for your procedure so you don't have to.

For a programmed procedure, give yourself 7 to 10 days to allow for the precertification process as the insurer may require additional testing or information from your doctor. If a form is required by the insurer, your doctor will need to fill it out and ensure they include all the pertinent information. That includes, but is not limited to:

• The complete medical notes clearly explaining the evolution of symptoms

• The D/M/Y the symptoms began

• The doctor’s diagnosis

• The estimated cost of the procedure

• Where the procedure will be taking place

• If applicable, the date of the procedure (if the insurer will be setting up a Guarantee of Payment, this information needs to be submitted)

• In some cases the insurer may request medical records from your General Practitioner from your home country, or medical records dating back before your policy start date

This information then needs to be emailed to the insurer where it will then be evaluated by their medical committee. If additional information is required, the insurer will reach out to the broker who will then contact the insured individual. Each precertification is done on a case-by-case basis so be sure to check with your broker if you’re unsure of needing to get something precertified.

One important thing to note: an approved precertification does not guarantee the claim will be approved. You will still need to go through the medical claim process to allow the insurance provider to do their due diligence. For example, you may be approved for a knee replacement surgery but if there is history of a knee injury that was not originally disclosed in your application, your claim will be denied and possibly your policy cancelled. If this happens and you feel the decision is not correct, all insurers have an appeal process. Please contact your broker should this be the case.

For emergencies, obviously they cannot be precertified as they are unplanned, but you must notify the insurer within 48 hours of being hospitalized to avoid a penalty. Please have your policy ID and birth date ready. We strongly recommend keeping a laminated copy of your insurance card on your person in case you are rendered unconscious due to an accident.

As always, when in doubt contact your broker or reach out to us directly at:

WhatsApp: +52 1 415 167 0886

Office Phone: +1 (800) 577-4308

Email: support@expatinsurance.com