Predetermination

Predetermination

Predetermination is a process established by health plans that allows a physician to submit a treatment plan to the health plan prior to surgery. The health plan reviews the treatment plan, patient's insurance benefit plan and medical policy to determine:

1. If the treatment is covered.
2. If the patient is a covered member.
3. The amount of co-payments/ co-insurance, deductibles.
4. The patient's plan maximum benefits.

While this process is typically used to verify benefits, it may also be an effective tool to use with health plans where you have had past difficulties or for new implantable hearing technologies where you expect to encounter resistance.

Predetermination Overview

For most health plans (except Medicare), the most effective way to secure insurance benefits for your patients and avoid misunderstandings about financial liability is to submit a predetermination request prior to scheduling the implant system surgery.

The predetermination process may vary between payers, with varying timeframes and requirements. some plans do not have a predetermination option.

In general, the predetermination process allows the payer to determine if the patient's plan covers the surgery and device. It is also a mechanism to ask the health plan's medical Director to review both the medical necessity and technology to determine coverage. Determination from the medical Director that the technology and surgical procedure is medically necessary reduces the risk of authorization denials.

Predetermination is:

• A process that allows physicians and other health care providers to determine, before treating a patient, if the procedure is eligible for coverage.
• Never a guarantee of payment. Final determination will be subject to valid eligibility and applicable benefits at the time of rendered services.
• An excellent way to educate the payers and Medical Director about the unique features and benefits of the implant system and the difference between hearing aids and the implant system.

Step One - Important Tasks to Help you Get Prepared

• Call the health plan and inquire where predetermination requests should be submitted (contact person, address, phone number).
• Obtain Medical Director's name, address, and phone number to personalize the request for review.
• Request peer-reviewed and published studies from your sales representative to support your request to the health plan.
• Advocate for your patient by explaining how the implant can specifically benefit the patient from a quality of life perspective.

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Step Two - Predetermination Request

Once a candidate has been identified, submit the predetermination request to his/her insurance carrier. The predetermination request includes a letter with supporting documentation.

Step Three - The Predetermination Letter should include:

• Patient information - name, date of birth, and policy number (include copy of patient's insurance card if available).
• Details of patient's medical history:
• • Current diagnosis, billing codes, and reason for treatment.
  • Duration and degree of illness or injury.
  • Summary of past failed treatments (course of hearing aids).
• Description of patient's current condition and treatment plan.
• Proposed procedure(s), technology (hearing implantable solutions), and rationale for treatment.
• Information stating that the implant system is NOT a hearing aid but is an implant.
• Proposed location of service and dates.

Step Four - Supporting Documentation

The supporting documentation accompanying the letter should include the following:

• Additional information such as the testing results and previous treatment history.
• Testing results, including current audiogram showing air and bone thresholds and word recognition/ discrimination scores and/or the results of other related diagnostic assessments such as ABR, OAE, CT scan, etc.
• Peer-reviewed literature or published scientific evidence to support the patient's treatment plan and use of the implantable hearing technology.
• Copies of FDA approval letters for the technology.
• Copies of prior authorization for use of the requested hearing technology in other patients' surgeries approved by the insurance plan.
• Copy of patient's insurance identification card.
• Product information.

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Step Five - Submission

Predetermination may be performed via phone, letter, fax or online. If you choose to predetermine over the phone, documentation of the call is critical. This includes:

• The date and time of the call.
• Name of the person you spoke with.
• A brief summary of the phone call.
• The predetermination number.
• A reference number from the insurance company representative regarding the call (if possible).

Once the predetermination request is complete, submit the predetermination letter and packet to the attention of the health plan's Medical Director (especially if you can find out their name).

Step Six - Follow-up / Confirmation

• Are there any exclusions or limitations that may prohibit or limit reimbursement? If the patient's insurance policy has an exclusion for hearing aid benefits, the provider should clearly state that the implant system is not a hearing aid, is medically necessary to treat the patient's condition(s), and meets the payer's criteria for coverage.
• Determine the payment rate or payment level at which the claim will be reimbursed and the patient's potential financial liability. Verifying the payment amount in advance enables the provider to determine if the patient will be able to meet their financial obligation or if there is a need to search for other funding sources.
• Will reimbursement be made for the postoperative fitting and adjustment of the sound processor?
• Are there any site of service limitations or requirements for implantation of the implant system?

If you have not received a response within 30 days, follow-up with the insurance plan with a phone call to check on the status.

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