Pre-Authorization vs. Pre-Certification: What’s the Difference?

Overview

Health plans often require approval before certain services are provided. Two common terms you’ll see are “Pre-Authorization” and “Pre-Certification.” Some payers use them interchangeably; others define them differently. This article explains the concepts, shows how they differ, and outlines what patients and providers should do to avoid delays or denials.

Quick Definitions

• Pre-Authorization (also called Prior Authorization, Pre-Auth, PA)

  • A review done before a service, procedure, medication, or device to determine medical necessity and benefit coverage.
  • Common for advanced imaging, specialty drugs, DME, certain outpatient procedures.

• Pre-Certification (also called Pre-Cert, Admission Certification)

  • A review and approval for planned inpatient admissions and some facility-based services, often including expected length of stay and level of care.
  • Common for elective inpatient surgeries, inpatient rehab/skilled nursing admissions, some high-cost facility services.

Note: Many insurers use “pre-authorization” to cover both. Always check the plan’s terminology.

Why These Approvals Matter

• They help confirm medical necessity and coverage before you receive care.
• Not obtaining required approval can lead to:
  • Service delays or cancellations
  • Denied claims
  • Increased out-of-pocket costs for the member

How They Differ (When a Plan Distinguishes Them)

• Focus:
  • Pre-Authorization: Approves the specific service/drug based on clinical criteria.
  • Pre-Certification: Approves the setting/admission and length of stay.
• Typical Use:
  • Pre-Authorization: Outpatient services, medications, imaging, DME.
  • Pre-Certification: Inpatient admissions (medical/surgical), inpatient rehab/SNF, some outpatient facility cases that require bed-days or special settings.
• Documentation:
  • Pre-Authorization: CPT/HCPCS codes, diagnosis, clinical notes, prior conservative treatments, ordering provider details, service location.
  • Pre-Certification: Admission date, admitting diagnosis, level of care, expected length of stay, facility info; may include procedure codes if relevant.

Common Examples

• MRI of the knee (outpatient): Usually pre-authorization.
• Elective hip replacement with planned admission: Pre-authorization for the procedure plus pre-certification for the inpatient stay.
• Specialty infusion drug: Pre-authorization (often includes site-of-care review).
• Admission to inpatient rehab after stroke: Pre-certification.
• CPAP device (DME): Pre-authorization; may require trial period documentation.

What Is Not Guaranteed

• Approval is not a guarantee of payment. Final payment still depends on:
  • Member eligibility and benefits at the time of service
  • Network status
  • Correct coding and billing
  • Deductibles, copays, coinsurance
  • Policy limits and exclusions

When Approvals Are Required

• Check the plan’s prior authorization list/formulary and medical policies.
• Factors that often trigger requirements:
  • High-cost services or drugs
  • Inpatient admissions
  • Services with specific clinical criteria or step-therapy rules
  • Out-of-network services

Emergencies: Most plans do not require prior approval for true emergencies. However, notification and/or certification shortly after admission is usually required (often within 24–48 hours).

Who Requests It?

• Typically initiated by the ordering provider or facility.
• Members can call to check if approval is needed, but clinical submission usually comes from the provider.
• Pharmacy benefit prior authorizations are often handled via ePA (electronic prior auth) between prescribers and the PBM.

What Information You’ll Need

• Member details: Full name, DOB, member ID
• Provider details: Ordering and rendering provider names, NPIs, TINs, contact info
• Service details: CPT/HCPCS codes, diagnosis (ICD-10), planned date(s), site of service
• Clinical documentation: History, exam findings, test results, prior conservative therapy, treatment rationale
• For admissions: Admitting diagnosis, level of care, expected length of stay, daily care plan when applicable

Typical Timeframes

• Standard/non-urgent: About 3–15 calendar days, depending on plan and service
• Urgent/expedited: Often 24–72 hours
• Pharmacy PAs: Frequently 24–72 hours once complete info is submitted

Tip: Submit early. Missing documentation is the most common cause of delays.

How to Check Requirements

• Provider portal or payer PA tool (code-based lookup)
• Phone number on the member’s ID card
• Payer medical policies and prior authorization lists
• Pharmacy benefit manager (PBM) formulary for drug PAs

Step-by-Step Process (Provider Office)

1. Verify eligibility and benefits; confirm network status.
2. Determine if prior authorization or pre-certification is required (check codes and site of service).
3. Gather clinical documents aligned to the payer’s medical policy.
4. Submit the request via portal, ePA, or phone/fax as directed by the plan.
5. Track status; respond promptly to requests for additional information.
6. Receive determination (approved/denied/partial) with an authorization or certification number.
7. Document the auth/cert number in the chart and share with scheduling and billing.
8. If admitted, perform concurrent review/updates as required for continued stay.

If Denied

• Review the denial letter and medical policy cited.
• Options:
  • Correct and resubmit with missing info
  • Peer-to-peer discussion (ordering provider with plan’s medical director)
  • File an appeal (follow timelines and include strong clinical support)
• Consider alternative covered treatments per the medical policy.

Best Practices

• Use accurate CPT/HCPCS and ICD-10 codes from the start.
• Align documentation to payer criteria (document failed conservative therapy when required).
• Keep a central log of pending and approved auths/certs with expiration dates and units/LOS.
• Confirm approvals still valid if dates shift; modify if needed before the new service date.
• Educate patients: “Approval confirms medical necessity and coverage rules, not final payment.”

Terminology Crosswalk (Common Variations)

• Pre-Authorization/Prior Authorization/Pre-Approval: Usually the same; focuses on service/drug medical necessity.
• Pre-Certification/Admission Certification: Often linked to inpatient/facility approval and length of stay.
• Predetermination/Pre-Treatment Estimate: Often used in dental/OON settings—an estimate of benefits, not an approval.
• Notification Only: Some services just require plan notification, not clinical review.

Frequently Asked Questions

• Do I need both pre-auth and pre-cert?
  • Sometimes. Example: A surgery that requires both procedure approval (pre-auth) and inpatient admission approval (pre-cert).
• Is emergency care exempt?
  • Usually yes for prior approval, but post-admission notification is commonly required.
• How long is an approval valid?
  • Varies by payer and service (e.g., 30–90 days). Check the approval letter.
• What if the service date changes?
  • Contact the payer to update or extend the authorization to avoid denials.
• Can members submit their own requests?
  • Members can initiate inquiries, but providers typically submit clinical documentation.

Key Takeaways

• Many plans use the terms interchangeably. When different, think: pre-authorization = service; pre-certification = admission/setting.
• Always check the plan’s rules for the member’s benefit plan and the specific codes.
• Submit early, include complete clinicals, and document the approval details in the chart and billing workflow.

📘 Instructions