Pre-certification — also called prior authorization or pre-auth — is how your health plan makes sure a recommended service or medication is truly needed before you get it. Your doctor tells us what care they're recommending, and a team of medical professionals reviews it to make sure it's covered under your plan.
Pre-certification requests are managed by our Utilization Management partner, American Health Holding (AHH).
Important: Pre-certification is not a guarantee of payment. Even if a service is approved, your actual coverage depends on your eligibility and benefits at the time your claim is processed. Benefits only apply to covered services received from in-network providers. Review your Plan Documents or call Member Services at (877) 522-5151 if you have questions about your coverage before receiving care.
What needs pre-certification?
Our full list shows which services need approval before you get care. It covers:
- All hospital stays
- Outpatient surgery and procedures
- Diagnostic services
- Ongoing care services
- Durable medical equipment (DME)
- Specialty medications
You can view the full pre-certification list here.
How do I get pre-certification?
Your doctor's office is responsible for submitting the pre-certification request on your behalf. Requests go directly to American Health Holding in two ways:
- Online: www.getprecert.com
- By phone: (833) 462-0088
What happens after a request is sent?
Here's what the process looks like once a request is submitted:
- Your doctor submits a request — they send in notes and records that show why the care is needed.
- AHH's Physician Review team looks it over — doctors on the review team check the request against medical guidelines to decide if the service is right for your situation.
- A decision is made:
- Approved — the service meets the criteria for medical necessity.
- Denied — either the information provided wasn't enough, or the service doesn't meet the criteria needed for coverage.
- Pended — more information is needed. Your doctor must send in additional records before a final decision can be made.
- You and your doctor are notified — if approved, care can move forward. If denied, your doctor can appeal — but the service will not be covered without a final approval.
Remember: An approval does not guarantee payment. Coverage still depends on your eligibility, your plan's benefits, and whether the service is covered and provided by an in-network provider at the time your claim is processed.
What to keep in mind
- Pre-certification is not a guarantee of payment — eligibility and benefits are confirmed at the time of claim processing.
- Coverage applies only to in-network providers — out-of-network care will not be covered even with a pre-certification approval.
- Skipping pre-certification can cost you — if pre-certification is required and you don't get it, your claim may be denied.
- For urgent situations — if your care needs to happen quickly, have your doctor call AHH right away at (833) 462-0088. Your request may be able to be sped up.
- True emergencies are different — in a real emergency, don't wait. Get the care you need first, then have your doctor notify AHH as soon as possible after.
What if a request is denied?
Both you and your doctor can appeal — which means asking for the decision to be looked at again. In most cases, it helps to have your doctor lead the appeal. They can send in extra records or a note explaining why the care is needed, which gives the appeal the best shot.
Here's what you need to know:
- You have 180 days from the date on your denial letter to file
- Include any records or paperwork that back up your case (like doctor's notes or test results)
- Send your appeal by mail to: American Health Holding Attention: Appeals Department 7400 West Campus Road, F-510 New Albany, OH 43054
A denial doesn't stop you from getting care — it just means your plan may not cover it. Talk to your doctor about next steps and ask if they can file the appeal for you. For additional help with a pre-certification determination appeal, you can also reach American Health Holding directly at (833) 462-0088.
Have questions about a pre-certification request or determination letter? Members and providers can reach the American Health Holding Utilization Management department directly at (833) 462-0088.