Because of the reimbursement model of international insurance, seeking pre-certification for medical procedures in Mexico is the key to making sure you don’t have to pay more out of your pocket than you should.
Pre-certification for medical procedures is the process of ensuring your hospital care and procedure will be covered by your insurance policy before any medical care takes place.
The process of pre-certification for medical procedures in Mexico protects you from being overcharged and allows you to set up a direct pay arrangement between the insurer and the hospital.
While pre-certification isn’t always a requirement, you should make it one.
Again, international insurance is based on a reimbursement model, meaning almost every procedure, test, and consultation is paid for out-of-pocket, with the client filing claims afterward.
The exception is that surgeries and some cancer treatments are eligible for direct pay arrangements as long as they are pre-certified by the insurer.
What Is Pre-Certification and Why Does It Matter?
Pre-certification for medical procedures in Mexico takes care of 3 crucial things.
#1 Confirmation the procedure will most likely be covered by your policy.
NOTE – Pre-certification does not guarantee coverage. For example, if something new appears in the medical notes AFTER you have been pre-certified, such as an undisclosed pre-existing condition, the insurance company can and may deny the procedure.
#2 It protects you from being charged for unnecessary fees or being charged more than the UCR (usual, customary, reasonable) costs, which would not be covered by your policy if you have already paid over the UCR.
#3 A direct pay option can be arranged with the hospital and/or surgeon with a GOP (Guarantee of Payment) letter issued by the insurer, which means you won’t need to pay costs beyond your deductible.
How to Get Pre-Certification for Medical Treatment in Mexico
Each international insurer has a similar process for pre-certification for medical procedures in Mexico for major medical events, such as surgery or long-term treatment for cancer.
A pre-certification form must be completed and submitted along with all supporting documents.
We suggest having the doctor fill out the form directly, as they will have all the information needed.
NOTE – All international insurance companies have bilingual staff, so it’s okay if your doctor doesn’t speak English and provides the information in Spanish.
Along with the filled-out form, the doctor will also need to provide the medical records, which clearly state the date of the onset of symptoms.
The date of onset of symptoms is important to confirm the medical issue was not ongoing before your policy effective date.
Remember, your first appointment with the doctor does not count as the date of the onset of symptoms.
The doctor will also need to provide all supporting tests and/or image results, the evolution of diagnosis, and the reason why this surgery, treatment, or procedure is required.
They must also include the estimated costs of the surgical team, which includes the cost of the surgeon, the assistant, and the anesthesiologist.
Most international health insurance policies do not cover additional assistants unless it can be proven they are medically necessary.
If special equipment will need to be rented or purchased, these costs should be included as well.
The hospital fees are not included in the pre-certification because things can take a turn during surgery, requiring additional treatment and hospitalization.
This will ultimately lead to a higher cost that was not already negotiated between the two parties.
The hospital fees are taken care of when the patient is discharged from the hospital, and the insurer and hospital communicate to come to an agreement on the cost of hospitalization.
Once the pre-certification form and supportive documents have been submitted to the insurance company, they will contact the surgeon and the hospital to offer a GOP (Guarantee of Payment) letter.
This legally binding document states that the insurer will pay for all costs the client is not responsible for.
If the hospital and doctor accept the GOP letter, you are set to go for your procedure.
Keep in mind that hospitals and providers are not required to work with foreign international insurance companies, and some don’t. That is their prerogative.
If the hospital or doctor doesn’t accept the GOP letter, there are a few options to consider.
- Pay the hospital and surgical team out-of-pocket and then file the claims for reimbursement. You will be responsible for collecting all the required documentation (regardless of pre-certification status).
- Find a different hospital that will accept the GOP letter.
- Request that the insurance company reach out to a coordinator or a TPA (third-party administrator). A TPA acts as the “middleman” and will be able to arrange for the direct pay between the insurer and hospital.
[Related Read: How Does International Insurance Work with Hospitals in Mexico?]
How Long Does Pre-Certification Take in Mexico?
Pre-certification for medical procedures in Mexico typically takes 3 – 5 business days, but it can be evaluated by the insurer in as little as 24 hours if it’s an emergency – and as long as all the required information has been submitted.
For anything that is not life-threatening, the recommended time to give yourself is 5 – 7 business days before the surgery or hospitalization.
Delays tend to happen on the doctor’s end if more medical information is needed, so it’s imperative to make sure your doctor provides everything required by your insurance company.
This includes…
- The completed pre-certification form
- Exact date when symptoms began
- Complete evolution of the diagnosis
- All written reports for tests and labs
- Estimated cost of the surgical team
- If applicable, cost of additional medical equipment
- Name of the hospital and contact person
What Happens If I Don’t Get Pre-Certified for Medical Treatments in Mexico?
If you don’t get pre-certified for medical procedures in Mexico, you will have to pay everything out-of-pocket and then file the claims for reimbursement.
This can be a major headache when recovering.
You also run the risk of being overcharged by the surgeon and/or hospital, especially in areas with a dense population of expats.
Also, depending on the insurer, if you don’t notify the insurer of your surgery within 48 to 72 hours, you run the risk of a penalty as high as 40%.
What this means is that when you file your claims, and they’ve been processed, you will only get 60% of your reimbursement back.
Be sure to get every surgery pre-certified and read through your policy wording very carefully to make sure the procedure and post-care treatments are covered.
If you have any questions or need clarification, ask your broker or the insurance company.
Step-by-Step Guide to Pre-Certification for Expats in Mexico
Use this step-by-step guide to help you apply for pre-certification for medical procedures in Mexico.
#1 Gather Your Information
- The pre-certification form filled out in detail by your doctor.
- The doctor’s complete medical notes that clearly state the date of the onset of symptoms (the first doctor’s appointment is NOT the date of the onset of your symptoms).
- Estimated costs of the surgery.
- Name and contact at the hospital.
- Written reports from images and tests, which support the need for the procedure.
#2 Contact Your Broker and/or Insurer
- Notify your broker you need surgery so they can assist with the pre-certification process. If you don’t have the pre-certification form, they can provide it.
- Have them explain the pre-certification process, including how to submit your documents, as well as the review and evaluation process.
- Ask for tips to ensure clear communication with your insurance company and the hospital.
#3 Submit Required Documentation
- Your pre-certification form.
- Estimated costs of the surgical team and any additional equipment required.
- Doctor’s medical notes outlining the evolution of diagnosis and the date the symptoms started.
- Any test results and written reports that support the doctor’s recommendations.
#4 Understand the Decision
- Prepare for the possible outcomes (approved, denied, partially approved).
- Carefully review the GOP letter to confirm the hospital information and costs are correct.
- Request an updated GOP letter if other claims are processed before your procedure.
- If you are denied, keep reading below for what to do.
#5 Follow Up and Confirm
- Confirm with your doctor that they have the GOP letter.
- Check that the hospital is aware of the direct pay arrangement when you check in.
- Confirm coverage details before the procedure to avoid surprises.
Why Pre-Certifications Get Denied
There are a few different reasons why pre-certification for medical procedures in Mexico is denied.
Here are some of the common reasons for pre-certification denial.
- 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.
- The requested service or procedure is not medically necessary. If the insurance company determines the requested service or procedure is not medically necessary, they can deny the pre-certification request. The insurance company will decide if the service or procedure is medically necessary based on the patient’s medical history and the established medical guidelines.
- Incomplete or incorrect information is given to the insurance company. Pre-certification requests require detailed information about the patient’s medical history, diagnosis, and proposed treatment plan. If the information is incomplete, inaccurate, or insufficient, the request may be denied.
- The procedure or service is considered a policy exclusion. Some insurance policies have specific exclusions, such as pre-existing conditions, certain types of treatments, or limits on certain medical services like physical therapy. If the requested service falls under a policy exclusion, pre-certification will be denied.
- Documents are missing. Supporting documentation, such as medical records, test results, or referrals, may be required to justify the medical necessity of the requested service. If these documents are missing, pre-certification can be denied.
If you receive a denial letter, it is critical to read the denial letter fully to understand the specific reason(s) for denial.
For instance, if your pre-certification was denied because of missing documents or incorrect information provided, you may be able to quickly remedy this situation and have the denial reversed.
However, if your pre-certification is denied because the particular procedure or treatment you seek is excluded from your insurance policy, you may have to consider other options.
Tips for Getting Pre-Approval for Medical Procedures in Mexico
Pre-certification for medical procedures in Mexico can seem overwhelming. Use these tips to make the pre-certification process easier.
- Don’t wait until the last minute to start the pre-certification process. Delays happen. You don’t want to have to put important medical care off longer or be forced to pay out-of-pocket.
- Contact your broker and/or insurer. Speak with them to find out exactly what you need and to request clarification for any questions or concerns you may have.
- Prepare written requests. Have exactly what you need to request from your doctor on hand, in English and Spanish.
Common Pre-Certification Mistakes to Avoid
There are several different parts of the pre-certification process for medical procedures.
Messing up on just one step can potentially cause delays, denied procedures, or extra charges.
Avoid these common mistakes.
- Waiting too long to start the process. It takes time for pre-certification to be approved. Don’t wait, or your procedure or treatment may be delayed.
- Not providing all necessary documentation. Make sure you have all the information needed from your doctor. If you do not submit all the required information, delays can occur, or your procedure can be denied.
- Misunderstanding coverage terms. This is KEY. Don’t assume certain things are covered. Ask questions. Seek clarification. Hospitals in Mexico do not bill and expect payment before allowing you to leave. You don’t want to find yourself stuck and unexpectedly asked to pay.
