As an expat living in Mexico, a denied pre-certification can be a major setback that leads to delays in treatment or unexpected out-of-pocket expenses.
If you are denied pre-certification, keep reading for reasons why you were denied and how you can appeal.
Why Pre-Certification Is Crucial for Expat Health Insurance
Pre-certification is the process of obtaining approval from your insurance company before receiving certain medical treatments or procedures.
Because international insurance is a reimbursement model, getting pre-certified before any medical procedure is the best way to ensure you don’t have to pay more out of your pocket than you should.
It also protects you from being overcharged.
And, in some cases – such as surgeries – pre-certification may mean you’re eligible for direct pay arrangements between your insurer and the hospital.
[Related Read: Pre-Certification for Medical Procedures in Mexico: Don’t Get Blindsided]
Common Reasons Why Pre-certification Is Denied
If you receive a denied pre-certification, make sure you read the denial letter in detail to understand the specific reason(s) for denial.
Because knowing exactly why will save you time and headache.
Here’s why most pre-certifications are denied:
- Documents are missing. A denied pre-certification may be as simple as missing medical records, test results, or referrals.
- Incomplete or inaccurate information. If the information provided is incomplete, inaccurate, or insufficient, the request may be denied.
- The procedure is not medically necessary. If the insurance company determines the requested service or procedure is not medically necessary, they will deny the pre-certification request. Whether or not a procedure or service is medically necessary is based on the patient’s medical history and the established medical guidelines.
- The pre-certification request is considered a policy exclusion. If the requested service falls under a policy exclusion – such as elective or cosmetic procedures – pre-certification will be denied.
- The procedure or service is not covered. The most common reason pre-certification is denied is because the requested service or procedure is not covered under the terms of the insurance policy. Some examples include experimental treatments, elective procedures, or services that exceed the policy’s limits.
- Out-of-network providers: While it’s considered a “free network” in Mexico – and you can choose any hospital or doctor – insurers also have contracts in place with many hospitals throughout Mexico. This doesn’t guarantee coverage, but it tends to streamline the pre-certification process from start to finish. If the hospital your surgeon or doctor works out of doesn’t work with insurance companies or accept a direct payment from your insurer, you will have to pay out-of-pocket for all services and file claims for reimbursement. Or see if you can change hospitals. Your insurer will most likely look for a third-party coordinator who specializes in direct pay arrangements between insurance companies and hospitals, but that could delay your medical procedure. Starting the pre-certification process right away is key to avoiding this kind of situation.
How to Appeal a Denied Pre-Certification
If you think your pre-certification was wrongly denied, you have the right to appeal the decision.
Unlike a denied claim – which can take insurers up to 60 business days to evaluate – a pre-certification appeal is much faster.
They are typically processed within 24-36 hours of the request due to the time-sensitive nature of the proposed treatment.
To appeal, your insurance broker should be your first point of contact.
They can guide you through the appeals process and help you gather the necessary documentation.
You will also need to contact your doctor to obtain comprehensive medical notes and evidence that support the need for the proposed treatment.
[Related Read: How to Appeal a Denied Health Insurance Claim]
What Are My Options If My Request Is Still Denied?
Unfortunately, there isn’t much you can do to fight a denied pre-certification if the appeal wasn’t successful.
At this point, you will have to find a way to cover the costs out-of-pocket.
You can always file the claim regardless of their initial denial – but unless you are able to provide new and compelling information – the verdict will most likely stand.
If you choose to continue to pursue overturning the decision based on medical proof, there is one more option: Arbitration.
Arbitration is a way to dispute a resolution outside of a traditional court system.
Rather than presenting in front of a judge, both parties agree on a third-party arbitrator to listen to their case and make an informed decision.
Read through your policy to ensure you are taking all the proper steps.
In the case of an arbitrator, the decision is binding in order to finalize the case – meaning the decision is final.
