GuideCM Pre-Certification & Case Management

 Pre-certification and Case Management are programs designed to help make sure you get the most appropriate medical care at the best cost to you. Our staff works closely with you and your doctor to get the maximum benefit from your health plan. 

• PRE-CERTIFICATION
• EMERGENT ADMISSION REVIEW
• CONCURRENT REVIEW
• RETROSPECTIVE REVIEW
• DISCHARGE PLANNING
• CASE MANAGEMENT 

Pre-certification is a review process to ensure that the treatment is medically necessary and appropriate. To avoid a penalty on a claim: A pre-certification needs to be submitted before the service is provided or up to 5 days aer the date of service. The most common services that oen require pre-certification include: 

1. Diagnostic Tests and Imaging

2. Surgeries and Procedures

3. Durable Medical Equipment (DME)

4. Specialty Care and Therapies

5. Mental Health and Substance Abuse Treatment

6. Inpatient Care 

 *Disclaimer: the list above is not to be taken as covered services. Call us at 866-837-1714 to determine the correct coverage based on your benefits plan. **Note: Pre-certification is not a guarantee of payment or coverage. Please review your benefits or contact your benefits plan for details. 

 Our Registered Nurse Case Managers use information from different sources to identify members who need case management. These sources include customer service phone calls, diagnosis reports, claims data, pharmacy claims data, and pre-certification reports.

One of our nurses works closely with you, your family, and your physicians to ensure that you have the information and support that you need. Whether you need specialized equipment, referrals, or simply a sympathetic ear, the nurse assigned to you can help you get what you need, when you need it.