Most commercial insurance companies require pre-certification for a hospital admission. Many companies also require pre-certification for tests (CT scans, MRI scans, etc.) and procedures (surgeries, scoping, etc.).
To pre-certify, you may call the phone number listed on your insurance card. Be sure to write down the date and time you called, and whom you spoke with. The Utilization Review Coordinator at Jefferson County Health Center would be happy to assist you. Hours available are Tuesday - Friday from 6 am - 4:30 pm at the Admissions desk. You may call at 641-469-4307.
If you fail to pre-certify, your insurance company may pay a smaller portion of the total charge, or may not pay at all. If you are unsure if pre-certificaiton is necessary, a phone call to the number listed on your insurance card should provide you with that information.
When your doctor orders laboratory, radiology or other diagnostic tests, Medicare will pay only for the tests that are related to your illness or symptoms. This is known as Medically Necessary Services.
Even if Medicare does not deem the test to be medically necessary, your physician may consider the services to be essential for your healthcare.
According to Medicare regulations, if Jefferson County Health Center staff believe Medicare will not pay for a service because it is not considered to be "reasonable and necessary" he/she may ask you to sign a form that says you agree to pay Jefferson County Health Center if Medicare denies the claim. This is called a waiver of liability statement.
Jefferson County Health Center staff must ask you to sign the statement before you receive the treatment or test, so you can decide if you want to receive the service, even through you may have to pay for it yourself.
After being informed that Medicare would not cover a test, if you choose to go ahead and have it, you are accepting responsibility for payment of the service.
Our Utilization Review Coordinator is available Tuesday -Friday from 6 am - 4:30 pm to assist you with this process. If you have questions you may call at 641-469-4307.
For assistance with pre-certification, your direct link at Jefferson County Health Center is 641-472-4111, and ask for the Utilization Review Coordinator.
How to File An Appeal
If you don't agree with the amount Medicare paid or with Medicare's decision to deny your claim, you have the right to appeal.
Your appeal rights are on the back of the Explanation of Medicare Benefits or Medicare Summary Notice. The notice will also tell you why your bill was not paid and what steps you can take.
You can first try to take care of it by calling Jefferson County Health Center or Medicare and explaining informally what you think is wrong. If you still think there is a problem, you can ask Medicare to review your claim by calling Medicare's toll-free number: 1-800-532-1285. You will need:
- Your Medicare number
- The date the services were done
- The specific reason for the review