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Precertification Request Form

Before Completing This Form

Please review the Inpatient / Outpatient precertification requirements listed below to determine whether the requested service or procedure requires prior authorization.

If precertification is required, please scroll down and complete the Precertification Request Form in its entirety. Include all required member, provider, and procedural information, along with supporting clinical documentation.

If precertification is not required, submission of this form is generally unnecessary for the services listed below, subject to applicable plan requirements.

Retroactive Reviews: Allowed up to 30 days (1 month).

Important Facility Requirement:

Members under Stephens County Hospital, Liberty Regional Hospital, and Evans Memorial Hospital MUST have these procedures performed at their respective facility if the facility can perform them.

Precertification IS Required For:

  • All inpatient stays
  • All surgeries
  • Arthroscopy or any joint surgery
  • Behavioral Health: Intensive Outpatient Program, Residential Treatment Centers, Partial Hospitalization Program
  • Biopsies - recommended where potential Cancer diagnosis exists
  • Bladder Repair
  • Cardiac Cath/Angioplasty
  • Chemotherapy
  • Cosmetic Surgery Potentials:
    • Blepharoplasty
    • Mammoplasty
    • Other
    • Varicose Veins stripping and ligation
  • Deviated Septum/Nasal Surgery
  • Dialysis
  • DME over $1,500
  • EBCT (Electron Beam Tomography)
  • Endoscopic Procedures
  • Extended Nursing Facility
  • Gastric Bypass/Panniculectomy/Abdominoplasty
  • Home Health Care
  • Hospice Care
  • Infusions (Infusion Therapy)
  • Inpatient Rehabilitation
  • Laminectomy/Spinal Surgery
  • Laparoscopy
  • Long Term Acute Care (LTAC)
  • MRI/CT/PET Scan - excludes bone density studies
  • Ongoing Wound Care
  • Pain Management such as:
    • Epidural Steroid Injections
    • Facet Injections
    • Intrathecal/Epidural Catheter & Drug Infusion Pumps
    • Medial Branch Blocks
    • Radiofrequency Ablations (RFA)
    • SI Joint Injections
    • Spinal Cord Stimulators
    • Sympathetic Nerve Blocks
  • Radiation Treatments
  • Select Implants
  • Skilled Nursing Facility
  • Transplants
  • Trigger Point Injections
  • 23-hour Observation Stay
  • Any procedure that has the potential to be experimental or investigational

Precertification is NOT Required For:

  • Cardiac Stress Test (Treadmill or Non-Nuclear)
  • Cataract Surgery
  • Colonoscopy
  • Electroencephalogram (EEG)
  • Electromyogram (EMG)
  • Esophagogastroduodenoscopy (EGD)
  • Mammogram
  • Nerve Conduction Study
  • Nuclear Scan
  • Pap Smear
  • Sleep Studies
  • Sterilization (Vasectomy and Tubal Ligation)
  • Therapies - Speech/OT/PT
  • Ultrasound (Also called Doppler Studies)
  • X-rays

Precertification Request

If your requested service requires precertification, please complete all applicable fields below and attach the necessary supporting documentation before submitting your request.

Required Information: Member Demographics

(Please verify eligibility prior to rendering service).

Yes
No
Primary
Secondary

Required Information: Provider Information
Important: Authorization Email Delivery

All precertification authorization information will be sent exclusively to the email address provided above.

To help ensure delivery, please add precert@secure.corehealthbenefits.com to your contacts or approved sender list. Check your spam or junk folder if the email is not received. Your organization's email security settings may also block delivery.

Required Information: Procedural Information



Yes
No

File Attachments:




(The maximum file size is 50MB. Submitting large files may cause a delay — please do not close your browser while the upload is in progress.)
Please be sure to complete the entire form and attach any office notes, pathologies, and diagnostics in the File Attachments box above. Once finished, click the Submit Precertification Request button below.