Pre-certification is a utilization management program that ensures that covered persons will receive the highest standard health care, in the most appropriate setting, and in the best interest of the patient.

NetCare shall require pre-certification review and approval for most outpatient elective surgery, cosmetic surgery, home health care, and major Diagnostic procedures including but not limited to PET Scan, MRI, CT and endoscopies; major in-patient procedures, chronic orthopedic surgery, neurosurgery, and all inpatient admissions. Please refer to the Complete List for the complete.

The purposes of the review for pre-certification are the following:

1. To determine the medical necessity of the service;
2. To determine the appropriate setting for service delivery.
3. To determine if requested service/procedure is covered benefit under member’s plan.

PLEASE NOTE:

• All pre-certification form/s must be completed by the Attending Physician or Nurse and submitted to NetCare with the necessary attachments at least 48 hours prior to services being rendered.
• The pre-certification request is valid for 30 days from the approval date.
• If the procedure has not been done within the valid period, a request for an extension from the UR department is necessary. Procedure done beyond the approval date will result to either non coverage or reduction of 50% of UCR charges
• Retro approval is subject to UR review. The following criteria should be met:
  
  1. Medical necessity and urgency was established by medical notes or records.
  2. Prior authorization from NetCare is not possible (weekends, holidays, after office hours.
  3. This is only allowed within 30 days from the date of service.
• Failure to comply will result in disallowance of the claims submitted or reduction of 50% of UCR charges. ( this does not apply to off island providers)

HMO AND EPO MEMBERS

For services not rendered by or not available at member’s Primary Care Physician (PCP), member is required to obtain prior authorization for all services on-island or off-island care. Primary Care Physicians are responsible for completing the PCP Referral Authorization Form to request that member(s) be referred to a specialist provider. PCP submits the completed form to NetCare’s Medical Management Department for review. A NetCare referral must be approved prior to services rendered off-island. Claims incurred without NetCare’s prior review will be disapproved. If the referral is for Off Island Services, a completed Pre-Certification Request Form for Services outside Guam must be submitted with the PCP Referral Authorization Form. The forms are submitted to NetCare’s Medical Management Department for review.

The following services DO NOT Require PCP Referral, Prior Authorization or Pre-Certification for NetCare HMO Plans:

1. Mental Health Services
2. Chiropractic Services
3. Labs, Regular Xrays
4. Female Members may self refer to OB/GYN for both Obstetrics and Gynecolog yservices.
5. Services which are not a covered benefit even if referred by PCP
6. Routine Eye Exam
7. Urgent/Emergency Care