insurance

Co-Insurance
If your plan includes co-insurance, then once your deductible has been met, you will share the cost of care with your insurance company on a split basis. Example: 80/20 – means your insurance company would pay 80% and you would be responsible for 20% of the bill. Insurance will not pay 100% of the medical bill until you have met your out-of-pocket maximum.

Co-Pay
A Co-Pay is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. The amount of the co-pay is determined by the individual’s insurance plan. For example, some HMOs require a $10 copayment for each office visit, regardless of the type or level of services provided during the visit.

Deductible
This is the amount you must pay out of pocket before the health plan will start paying towards your medical bills. This amount is reset each plan year.

Out-of-pocket
Once you have paid a certain amount (out-of-pocket maximum) towards your Maximum medical bills in a plan year, your insurance provider will then pay all of your covered services for the rest of the plan year.

Plan Year
This is a 12-month period and may not be the same as the calendar year. To find out when your plan year begins, you can check your plan documents or ask your employer. (Note: For individual health insurance policies this 12-month period is called a “policy year”)

Misc.
Depending on your Benefit Coverage Requirements, your insurance company may
(1) make a full payment on your claim
(2) make a partial payment on your claim
(3) deny the claim

 Step (1) - Visit to the Doctor
If you have health insurance, you will provide your updated insurance information to the front desk on the day of your visit.

Step (2) - Claim is submitted by Doctor's Office to your Insurance Company
Claim is submitted by Doctor’s Office to your Insurance Company. A Claim is the form filled out and sent by your doctor to the insurance company asking for payment from your insurance provider for the medical services that were rendered. The insurance industry has established that services rendered be described using a medical coding system known as CPT Codes (Current Procedural Terminology). These codes are organized for ease of use by both the insurance companies and physicians. Many times, the short description language accompanied by the code on the patient statement, is referring to the section of the coding book and does not completely reflect the services performed. A list of CPT codes with their full description can be found on the American Medical Association website.

Step (3) - The Insurance Company Adjudicates the Claim
Adjudication is the term used in the insurance industry to refer to the process of paying claims submitted or denying them after comparing claims to the benefit coverage requirements.

Step (4) - An Explanation of Benefits (EOB) is sent to you from your Insurance Provider
An Explanation of Benefits (EOB) is sent to you from your Insurance Provider. An Explanation of Benefits (EOB) is a summary sent to you by your insurance company showing what services you received, what portion of the cost your health plan paid to your doctor, and showing if you owe the doctor any additional balance for those services rendered. An EOB is Not a Bill. This EOB is also sent to your doctor's office. 

Step (5) - After the claim has adjudicated, a Patient Statement is sent to you from your Doctor's office
After the claim has adjudicated, a Patient Statement is sent to you from your doctor’s office. A Patient Statement is a bill sent to you from your doctor’s office if there is a patient responsibility remaining. The statement will show how much money you owe for the services that were rendered after insurance has been billed and the claim has been adjudicated.

You have an Unmet Deductible
You have not met your out of pocket expenses. Your insurance plan may require a deductible or co-insurance limit to be met before they will remit payment for a service.

Service is not medically necessary
Your insurance plan has determined that the treatment received is not considered medically necessary.

Service is not a covered benefit
Your insurance does not cover this service/treatment. You will need to pay out of pocket for those services.

Out-of-network provider
You have used a provider who is not in your health plan’s network and the services may not be covered or may be subject to a coinsurance.

Past Timely Filing
Most insurance companies allow 90 days from the time of service for the claim to be filed. If a claim is filed after this period, it will be rejected. That is why it is so important to provide updated insurance information at the time of service.

No Pre-Authorization
Some insurance plans require pre-authorization for certain procedures. If your insurance denies services, you will be responsible for full payment. 

Authorization Timed Out
Authorization is usually granted for a specific duration of time. If services are performed after the authorization period, the claim will be denied.

You were late in making your Individual Policy payments
If a patient is behind on their individual policy payments, the claim may be denied. This includes COBRA and month-to-month policies such as those in the HealthExchange Market.

No Physician Referral
Some insurance plans require a referral from the patient’s primary care provider before services can be rendered. If service is provided before a referral is confirmed by the insurance company, the claim will be denied and the charges will be the patient’s responsibility.

You have an Out-of-State Insurance Plan
Claims may be denied if you are treated in one state but your insurance plan is out-of-state and a referral is required. It is your responsibility to verify that you have out-of-network and out-of-state benefits. Many policies in the HealthExchange Market only cover the state where the policy was originally taken out.

 If you have more than one health insurance plan, one plan becomes your primary plan. It pays your claims first. The second plan may pay toward the remaining cost, depending on the plan. Those plans need to work together to make sure you’re getting the most out of your coverage. This process is called Coordination of Benefits or COB.

Updating your Coordination of Benefits helps your insurance claims process faster and maximizes your benefits, which can lower your out-of-pocket costs. It is important that you keep your information up-to-date. If you receive a request regarding your Coordination of Benefits, please respond as quickly as possible. If your insurance does not receive your response, they may reject your insurance claim.

Accident Information Explained
Quite often insurance companies will request additional information from you, the member, regarding a claim that has been filed on your behalf before they will process and pay the claim to the provider. It is your responsibility to contact your insurance in this case to provide needed/required information to them. Otherwise the balance becomes yours to pay until such information is given to the insurance company by the patient and the claim is reprocessed for payment. The provider cannot provide this information to the insurance company on your behalf.

What is a Medicare Advantage Plan? A Medicare Advantage Plan is a Medicare policy that is administered by a private insurer (like United Healthcare, Aetna, Cigna etc) that offers the same benefits as traditional Medicare plus additional benefits that traditional Medicare may not cover.

What is covered under a Medicare Advantage Plan? Medicare Advantage Plans are required to cover everything that is covered by traditional Medicare, plus, they often also cover dental, vision, wellness and prescriptions.

Is there a deductible or co-insurance? Yes. In addition to the Medicare part B premium, you usually pay a monthly premium for the Medicare Advantage Plan. Each plan is different so it is important to know the costs associated with these plans before you choose one.

Do I still use my traditional Medicare? No, if you opt for a Medicare Advantage Plan, your traditional Medicare is not used and will not cover any services.

Additional Information on Medicare Advantage Plans
Click HERE for more detailed information about Medicare Advantage Plans.

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