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Insurance coverage

Do you know what your health insurance covers? Every plan is different and they may change. What you don't know could cost you.

Insurance policies can be confusing. And you don't want to find out that something isn't covered at the last minute. It could mean money out of your pocket. It's best to educate yourself on what your health insurance covers before you need to use it. Below are a few things you should know:

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Do you need a referral?

Your plan may require you to get a referral from your primary care doctor before you can see a specialist or go to a specialty clinic. To find out if your plan requires a referral for services other than your primary care visits, you should contact your insurance company's member services department. 

How do you get a referral? 

In most cases, you will need to contact your assigned primary care doctor to request a referral. You may need an appointment with your primary care doctor, so you should contact them as soon as possible. 

How long does it take to get a referral? 

Most insurance companies require 7 business days or more to process a referral request.

Can I see the specialist if I need a referral, but don't have one yet? 

You will need to check with the specialist's office, but in most cases your insurance company will not approve referrals after you have already seen the doctor. These services may not be covered by your insurance company and you may be responsible for the full charges.

Do you need preauthorization?

Some plans require that you get an approval or authorization to see certain doctors or have some procedures in advance. Insurance company's preauthorization or preapproval requirements vary by plan. Your employer group may also opt out of certain preauthorization requirements. You should always check with your insurance company before having any procedures done to make sure their preauthorization requirements have been met. Keep in mind that a preauthorization code may not mean that services are covered.

Who will get my preauthorization? 

The doctor who orders your procedure will usually request the preauthorization from your insurance company on your behalf. You may be asked to provide information to assist in getting the preauthorization. Check with your doctor or insurance company to be sure your preauthorization is complete before you receive services.

What is a predetermination of benefits and when is it needed?

A predetermination of benefits is a written request for benefits, which is usually submitted to your insurance company by the doctor providing the service. The insurance company will review your policy and will send an explanation of covered benefits based on your policy.

What's covered in an emergency?

Some kinds of emergency services require notification or an authorization. This might include an emergency hospital admission. In most cases the hospital will contact your insurance company on your behalf. You may be asked to provide information to assist in getting the notification or authorization. Check with the hospital or insurance company to be sure the notification or authorization is complete once you have been admitted.

What if my ER doctor is not a participating provider with my plan?

If your health plan doesn't have a contract with the ER doctor, even if it does contract with the ER, you may have to pay part or all of the doctor's bill. Because plans vary, and offer different levels of coverage for out-of-network providers, you may want to consider the coverage a plan offers for any out-of-network services.

Carve-outs

These are certain services that are separated from general health care contracts, meaning that the health plan may have different contracts and payment arrangements for those services. Carve-outs may include prescription drug benefits, vision care, dental or other similar types of services. Carve-outs may also include mental health coverage which is contracted with vendors with expertise in such specialties as substance abuse, transplants or care for premature infants. For employers, carve-outs can help reduce risk and lower financial costs.

What's a Coordination of Benefits? 

If you have more than one type of insurance coverage, including government programs, be sure to let both insurance companies know about other coverage. This will help reduce claim related issues and billing delays. It also helps you understand which order your insurance should be billed in. You may be required to fill out a form for your insurance company once a year, even if you don't have more than one type of insurance coverage.

What's the difference between Medicaid and CHIP? 

Children's Medicaid offers free health care services to children under 19 years of age whose families have limited income and resources. CHIP is a health insurance program for children under 19 years of age whose families have low income and resources, but earn too much to receive Medicaid and do not have private health insurance. Enrollment fees and copayments are based on the family's income.
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