Eligibility and Precertification
When a healthcare provider submits a claim to TribalCARE, we immediately establish eligibility, verify benefits and determine coverage according to the Tribal Enterprise’s plan document.
Precertification procedures are part of the TribalCARE Utilization Management services that goes into effect when a hospital or doctor recommends inpatient hospital admissions or specific outpatient procedures.
Precertification is conducted by our highly-qualified Registered Nurses (RNs). These clinical professionals evaluate medical treatment plans and conduct a medical review to ensure medical necessity and the appropriate setting for each level of care.
Precertification requirements and the list of procedures that require precertification vary according to the healthcare plan specified by the Tribal organization, which empowers your organization to tailor the benefit plan to the specific needs of your enterprise.