Yes. Certification is required for certain outpatient surgical and diagnostic imaging procedures.
Certification is a review process used to determine if certain services are medically necessary according to HealthChoice guidelines. Certification is performed by either the HealthChoice certification administrator or by the HealthChoice Health Care Management Unit, depending on the type of service.
The provider must obtain certification under certain situations, including when the member or the member’s covered dependents:
- Are admitted to a hospital or are advised to enter a hospital.
- Require certain surgical procedures that are performed in an outpatient facility.
- Require certain diagnostic imaging procedures.
For more information, please refer to the HealthChoice Network Provider Manual.