Why Precertification?

For hospital admissions, some outpatient procedures, and some medications, Nippon Life Benefits requires precertification. This process helps to reduce unnecessary medical expenses and ensure coverage is available should you or a family member require inpatient or outpatient care.

Member Requirements

Depending on your benefit program, failure to obtain precertification may result in reduced benefits. Please check your benefit booklet-certificate for details. Your benefit booklet-certificate can be found on the member portal. Keep in mind that all eligible services are subject to medical necessity requirements and plan provisions.

If you or a family member are in need of care, members should call the number located on the back of their benefits card.

Outpatient

View the list of outpatient services that require precertification, as well as FAQs about the outpatient precertification process.

Inpatient

Non-Emergency Stays

You, a family member, your doctor, or facility must call the Precertification number on the back of your ID card prior to any stay. Please be prepared to provide your benefits program ID number, the patient’s name, a reason for admission, the date of expected admissions, the doctor’s name and phone number, and the facility’s name and phone number. The utilization review staff considers the patient’s condition and proposed treatment plan to determine the number of days authorized for stay.

Emergencies

If you or a family member is admitted due to an emergency, you must call the precertification number on the back of your ID card within two working days of admission.

Maternity Delivery

New mothers and newborns receive automatic authorization for a minimum 48-hour stay including the day of delivery for a normal delivery or a minimum 96-hour stay including day of delivery for a caesarian section. If a longer stay is medically necessary, the patient or their representative must call before the end of the authorized time frame.

Please Note: The member or the provider can call for precertification.

Pharmacy

Drug Formulary

State-Specific Drug Listings

Specific Drug Listings for Illinois Group Contracts:

Specific Drug Listings for Texas Group Contracts: