Precertification Process

You can request precertification through the following channels:

Online: www.MyPromiseHealthPlan.com

Phone: (855) 504-6363

Fax: (717) 295-1208

Precertification, also known as prior authorization or prior approval, by Promise Health Plan is required for inpatient services and some outpatient services and surgeries. Please refer to the precertification list below.

Services Requiring Precertification

Requirements for Initial Certifications

When you call for precertification, be prepared to provide all the following information:

• Member name, address, phone number, and the ID number shown on the front of the member’s ID card
• the patient’s name, address, phone number (if not the member)
• admitting physician’s name and phone number
• name of facility or home health care agency
• date of admission or proposed date of admission
• condition for which patient is being admitted 

Time Frames for Initial Certifications

For non-urgent care, you or your authorized representative should call Promise Health Plan at least 15 calendar days prior to initiation of services or continuation of services after Medicare benefits are exhausted. For urgent care, you or your authorized representative may call Promise Health Plan within 48 hours or the next business day, if later, after the initiation of services. If no additional information is required, the determination of coverage will generally be completed within a reasonable period of time, but no later than 15 calendar days from receipt of the request. 

In the event Promise Health Plan receives a communication that fails to follow the precertification procedure described above but communicates at least your name, a specific medical condition or symptom, and a specific treatment, service, or product for which precertification is requested, you (or your authorized representative) will be notified orally (and in writing, if requested) within five calendar days of the failure to follow the proper procedure.

If Promise Health Plan needs additional time to make a decision due to circumstances beyond its control, you will be notified within the 15 calendar days of the circumstances and the date by which Promise Health Plan expects to render a decision. If the circumstances include a failure on your part to submit necessary information, the notice will specifically describe the needed information. You will have 45 calendar days to provide the information requested and Promise Health Plan will complete its determination of the claim for certification no later than 15 calendar days after receiving the requested information. 

Failure to respond in a timely and complete manner will result in a denial of the requested certification.

Time Frames for Certification Extensions

If you request an extension of a previously approved hospitalization, skilled nursing facility stay, or ongoing course of treatment, and the request involves non-urgent care, the extension request will be processed within 15 calendar days after the request is received. If the inpatient admission or ongoing course of treatment involves urgent care and the request is received at least 24 hours before the scheduled end of a hospitalization or course of treatment, the request will be ruled upon and you will be notified as soon as possible but no later than 24 hours after the request is received. If the inpatient admission or ongoing course of treatment involves urgent care and the request is received less than 24 hours before the scheduled end of a hospitalization or course of treatment, the request will be ruled upon and you will be notified no later than 72 hours after the request is received. 

If a Certification Changes

If Promise Health Plan determines that the hospital or skilled nursing facility stay or course of treatment should be shortened or terminated before the end of the fixed number of days and/or treatments, or the fixed time period that was previously approved, we will:

• notify you of the proposed change, and
• allow you to file an appeal and obtain a decision before the end of the fixed number of days and/or treatments or the fixed time period that was previously approved. 

If a Certification Is Denied

If your request for a certification or certification extension is denied in whole or in part, we will provide you with a written Notice of Certification Denial within the time frames indicated above.

The Notice of Certification Denial will include an explanation of the denial, including:

• the specific reason(s) for the denial
• reference to the Medical Plan provisions on which the denial is based
• if the denial is due to a lack of information necessary for certification, a description of any additional material or information needed and an explanation of why such material or information is necessary.
• a description of the Medical Plan claim review procedure and applicable time limits
• if the denial relies upon an internal rule, guideline, protocol or other similar criterion, either a copy of that criterion or a statement that such criterion was relied upon and will be supplied free of charge, upon request
• if denial was based on custodial care, medical necessity, experimental/ investigational treatment, or similar exclusion or limit, either an explanation of the scientific or clinical judgment, applying the terms of the Medical Plan to your medical circumstances, or a statement that such explanation will be supplied free of charge, upon request.
• a statement that you have a right to appeal.