Preauthorization and Procedure Codes

Any time someone receives a service from a provider, the service(s) rendered are tied to established Procedure Codes. These codes are used to tell the insurance carrier what kind of service was rendered, and how they will pay out for it based on the insurance plan benefits.

Zenefits cannot provide costs for procedures. A doctor can submit a preauthorization to the insurance carrier directly for this.

Preauthorization

Preauthorization, also known as precertification, is the process of submitting procedure codes for services that need to be deemed medically-necessary for the insurer to cover them, such as some surgeries or rehabilitation services.

  • The provider submits the Procedure Codes and other details to the carrier for the carrier's approval.
  • The plan's Summary of Benefits and Coverage will denote if preauthorization is required for certain services.

Along with confirming codes and medical necessity, preauthorization will also confirm the benefit that the enrollee would receive before the service is rendered. This can help determine how much the enrollee would be responsible for once the services are complete and the claim has been submitted to the carrier.

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