Prior Authorization/Precertification

What is Prior Authorization/Precertification?

According to HealthCare.gov, Prior Authorization is, “A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.”

Prior Authorization, Preauthorization, and Precertification: What’s the difference?

These words are all considered industry standard terms for the same process and can all be used interchangeably to describe the act of verifying various methods of care through your insurer.

Why Prior Authorization?

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

Depending on your benefit program, failure to obtain prior authorization 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.

List of Services

Contact Customer Service to Confirm Coverage: 800-374-1835

This material and information is intended for informational purposes only. This material and information is subject to change, at any time and without notice, by Nippon Life Insurance Company of America.

Frequently Asked Questions

1. I have an upcoming outpatient procedure, what do I do?
   Outpatient services requiring prior authorization/precertification generally include the following: Complex imaging, certain cosmetic/reconstructive surgery and back surgery. For a current list of outpatient services requiring prior authorization/precertification, please see the Nippon Life Benefits website at (www.nipponlifebenefits.com). We ask your provider to contact us 15 days prior to the procedure being performed. The number to contact is 877-518-0770.

2. What if my procedure is urgent and I don’t have 15 days to wait for an approval?
   Nippon Life Benefits can review on an expedited basis if all the required information is received. Please be aware that approvals are based on medical necessity and if a procedure is done prior to a medical review, your claim may be denied for additional information or for medical necessity.

3. What if I have a procedure scheduled for the first week after the plan anniversary/renewal?
   Clients will receive information related to the outpatient precertification/prior authorization process 45 days prior to plan anniversary/renewal, to share with members. Members will receive new ID cards prior to the plan anniversary/renewal to reflect the new requirement.

4. Do services rendered in a physician’s office require prior authorization/precertification?
   Yes, all outpatient services listed require prior authorization/precertification regardless of where the service is rendered.

5. I wasn’t aware that outpatient prior authorization/precertification was required as I don’t see anything listed in my booklet?
   Outpatient prior authorization/precertification is a new service that Nippon Life Benefits is offering on your plan anniversary date starting 1/1/2021. Please consult with your employer for your effective date.

6. Can the outpatient prior authorization/precertification process be completed by telephone?
   Yes, the process can be completed by telephone as long as all the required information from the provider is received.

7. Is there a specific form that needs to be completed?
   No, there is no specific form that needs to be completed.

8. How will I know if my outpatient service has been approved?
   A letter will be mailed to the provider, facility and member outlining the decision of the review.

9. What are the next steps if my procedure has been denied?
   You have the right to appeal the decision. The appeal process will be outlined in the denial letter that is sent to the provider, facility and member. You can also refer to your booklet for your individual appeal rights.

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 prior authorization.

Drug Formulary

State-Specific Drug Listings

Specific Drug Listings for Illinois Group Contracts:

Specific Drug Listings for Texas Group Contracts: