Precertification/Prior Authorization
Precertification/Prior Authorization Rules and Requirements
Most plan sponsors require precertification/prior authorization for certain services including all hospital admissions and many outpatient procedures.
Any elective procedure or service must be pre-certified at least five (5) days prior to the scheduled procedure or service date. Failure to pre-certify may result in a reduction of the member’s benefits. BHN reserves the right to pend or deny a claim for additional information.
When verifying benefits and eligibility, always confirm whether prior authorization is required for the service being rendered. This should happen before the service is rendered. The telephone number for precertification can be found on the member’s ID card.
Precertification/Prior Authorization Examples
The following services generally require precertification/prior authorization:
- Ambulatory Surgery (regardless of setting)
- Chiropractic Services
- Physical or Occupational Therapy
- Podiatric Services
- Speech Therapy
- Audiology Services
- High Tech Radiology Services
- Hyperbaric Oxygen
Submitting a Pre-certification/Prior Authorization Request
MagnaCare products:
If the plan sponsor has selected MagnaCare to administer their medical management benefits, prior authorization requests can be submitted within the provider portal.
Submit inpatient pre-certification requests by fax to 516-723-7399.
Submit outpatient pre-certification requests by fax to 516-723-7306.
Or, call Provider Services at 888-362-4624.
Create products:
Submit pre-certification requests by fax at 1-516-723-7392.
Or, call our Provider Services team at 1-844-427-3878
Decision Timeframe
Pre-certification/prior authorization decisions will be provided within fifteen (15) days of receipt.
Decisions on urgent care requests will be provided within seventy two (72) hours.