Precertification
Precertification is approval you may need from your health insurance plan before getting certain services, tests, or procedures. If precertification is required and not received, the plan may cover less of the cost or may not cover the service at all.
Last updated: August, 2026
Key Takeaways
- Precertification is a plan approval step that may be required before certain care.
- It is often used for higher-cost services, imaging, surgeries, or specialty treatments.
- Your provider usually helps request precertification, but you may still be responsible for confirming it is done.
- Missing precertification can lead to higher out-of-pocket costs or denied coverage.
- Checking requirements ahead of time can help you avoid delays and surprise bills.
- If precertification is denied, you can appeal, and your doctor may submit more medical information to support it.
What is Precertification in Health Insurance?
Precertification is a process where your health insurance plan reviews a requested service before it happens to confirm it meets coverage rules. It is sometimes called prior authorization. Plans may require precertification for certain procedures, imaging tests, hospital stays, or specialty medications.
The goal is to confirm the service is medically necessary and covered under your benefits. In many cases, your doctor’s office or hospital submits the request, along with supporting medical information. Even so, it is a good idea to understand when precertification is needed so you can help avoid delays, claim denials, or unexpected costs.
How This Shows Up in Real Life
Your doctor recommends an MRI for ongoing knee pain. Before the test is scheduled, the imaging center checks whether your plan requires precertification. Your provider submits the request to the plan, and once it is approved, you can move forward with the MRI under your plan’s coverage rules.
How Precertification Affects What You Pay
Precertification can affect your costs because it can change whether a service is covered and how much the plan pays. If a service requires precertification and it is not approved in advance, you may be responsible for a larger share of the bill, or the claim may be denied. This can be especially expensive for high-cost services like advanced imaging, procedures, or hospital care. Planning ahead, staying in-network, and confirming precertification requirements can help you avoid delays and protect your budget.
Where to Find This in Your Plan Details
To find out whether a service needs precertification, you can review:
- Your Summary of Benefits and Coverage (SBC)
- Your Schedule of Benefits
- Your member handbook or policy documents
- Your health plan’s website, your Ambetter Health online member account, or the mobile app.
These resources may list services that require precertification and the steps to follow.
How This Changes Across Marketplace Plans
Precertification rules can vary between Marketplace health insurance plans. Differences in network type, plan category, and benefit structure may affect which services require approval and how claims are handled.
| Plan Features | How It May Differ | What It Means for You |
|---|---|---|
| Service Type | Some plans require precertification for imaging, specialty medications, surgeries, or hospital stays. | You may need approval before scheduling certain services to ensure coverage. |
| Network Type | Plans with narrower networks may have stricter rules about which providers can request or perform approved services. | Staying in-network may be required for approval and lower costs. |
| Out-of-network Care | Out-of-network services may have separate precertification requirements or may not be covered. | You could face higher or denied claims if approval is not obtained. |
| Plan Design Differences | Even within the same plan category, services requiring precertification can vary. | Always review your specific plan documents before scheduling care. |
FAQs About Precertification
Often, yes. Many plans use “precertification” and “prior authorization” to describe the same approval process. Your plan documents will explain which term is used and when it applies.
Your provider often submits the request, but you may still be responsible for making sure it is completed. If you are scheduling a service, it is smart to ask your provider or facility whether precertification is required.
Timing can vary based on the service and the information needed. Some requests are handled quickly, while others take longer if additional records are required. Checking early can help prevent delays in care.
Your claim may be denied or covered at a lower level, depending on your plan. That can lead to higher out-of-pocket costs. If you're unsure, contact Member Services before you receive the care.
Not always. Precertification is an approval step, but you may still have costs based on your deductible, copay, or coinsurance. Coverage can also depend on using in-network providers and following plan rules.
Related Terms
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Learn MoreWondering how this applies to your Ambetter Health coverage?
Already covered? Your benefits vary by plan and location. Limitations and exclusions may apply. Contact Ambetter Health or call Member Services at the number on the back of your Member ID Card for answers specific to your coverage.
Not yet a member? Our licensed agents are ready to help you find the perfect plan. Call 855-680-3270 (TTY: 711), Monday-Friday 8 a.m. to 9 p.m. ET, to discuss your health insurance options.
Sources:
HealthCare.gov -Preauthorization
Mayoclinic.org - Insurance approvals: pre-certification and prior authorizations
Ama-assn.org - Prior authorization practice resources