Millions of American’s pay for their health insurance without knowing what their insurance covers and what rights and responsibilities comes with their coverage. To get the most out of your health insurance, there are some basic things you should know.
Every health insurance policy contains a preexisting clause. An insurance company defines a preexisting condition as any condition that was treated during a specific period before the policy went into effect. Preexisting condition waiting periods can range from six months to two years, depending on the policy. If you had coverage through another company and have not gone more than three months without coverage, the preexisting waiting period can be reduced by providing a letter of prior coverage from your previous insurance company. Even if you have not received care prior to enrollment in a new insurance plan, your insurance carrier will likely contact you for additional information about any treatments. Failure to provide this information may cause the carrier to deny your claim, and you will be responsible for the cost of your doctor or hospital visit.
A common cause of claims denials are services for diagnoses that are not covered by the policy. Common examples of non-covered diagnoses are TMJ, fibromyalgia, and obesity, but check your policy because some insurance policies are beginning to cover these diseases. There are also procedures that are not covered. If you require treatment for a condition that is not covered by your policy or your doctor believes you need a procedure that is not covered, you can enlist your doctor’s help for a waiver. With proper documentation, you can sometimes receive coverage for non-covered services and conditions, but you are required to file an appeal and provide copies of medical records and any research studies to bolster your case.
If you require a hospital visit, most insurance carriers require that the visit be preapproved. Most doctor’s offices will obtain preapproval for you, but ultimately it is your responsibility to make sure that all of the necessary steps are taken before you are admitted. When you are scheduled for surgery, ask your doctor if precertification is handled in the office. If it is not, contact your insurance carrier and they will walk you through the steps. If you are admitted for an emergency condition, most insurance companies require a phone call within 24 hours of admission.
Health insurance is a partnership between you, your doctor and your insurance company. By knowing what to do in common situations, you can increase your chances of having your claims approved and your bills paid.