PSI Ohio Insurance Practice Exam

Which provision requires claim information to be submitted to the insurer prior to treatment?

1. Postcertification provision

2. Pre-certification provision

3. Retrospective review

4. Claim waiver

The correct answer is: Pre-certification provision

The pre-certification provision is designed to ensure that medical treatments or procedures are deemed necessary and appropriate by the insurer before they are performed, which helps control healthcare costs and improve patient outcomes. Under this provision, policyholders or healthcare providers are required to submit relevant claim information to the insurer for approval prior to the treatment taking place. This practice allows insurers to evaluate the necessity of proposed medical services, ensuring that the treatments align with the policy coverage and guidelines. In contrast, the postcertification provision typically refers to the process where treatment information is reviewed after the services have been rendered, which does not address the requirement for pre-approval. Retrospective review also occurs after services have been provided, looking back at the claims to determine whether they were justified. A claim waiver does not pertain to the process of submitting claim information for pre-treatment approval but instead refers to the relinquishment of the right to make a claim.