GuideCM Pre-Certification & Case Management

Using Pre-certification and Case Management, you can feel confident you’re getting the care you need at a cost that works for you. Our team partners with you and your doctor to help you maximize the benefits of your health plan. 

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

 Pre-certification helps make sure your treatment is medically necessary and appropriate for your needs. To avoid a penalty on your claim, remember to get pre-certified before you receive the service — or no later than 5 days after you’ve had it.

Here are some common services that often require pre-certification:**

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

Please note: The list above isn’t a guarantee that these services are covered. Always check with us first — give us a call at 866-837-1714 to confirm what’s included in your benefits plan.

Important: Pre-certification doesn’t guarantee payment or coverage. Be sure to review your plan details or reach out to your benefits provider if you have any questions

Your Registered Nurse Case Managers gather information from different sources — like customer service calls, diagnosis reports, claims data, pharmacy data, and pre-certification reports — to find members who might benefit from extra support.

Once identified, one of our nurses will work closely with you, your family, and your doctors to make sure you have the information and help you need. Whether it’s getting specialized equipment, arranging referrals, or just having someone to listen, your dedicated nurse is here to guide you every step of the way