Precertification is a process still used by health insurance companies to control health care costs. Although we believe precertification is unnecessary and not cost-effective, in those instances where precertification is still being utilized, we suggest that the following procedures be adopted. This statement suggests guidelines that should help achieve this goal while allowing optimal access to care for children. The precertification process is a utilization management tool used to control hospital admissions, utilization of services, and medical facility expense.
Children respond to illness and injuries differently from adults.
Critical symptoms may develop more rapidly, and children often cannot appropriately communicate the severity of their condition. For these reasons children frequently require early and expedient physician evaluation and in-hospital monitoring. Delay that compromises a child's care or clinical outcome is not acceptable as part of a cost-containment screening process. The timely and appropriate approval of pediatric referrals to hospitals and physicians must be of paramount consideration in any established approval process or procedure. The following guidelines are meant to help achieve the goals of utilization management and optimal care for children.