How can my employees understand insurance coverage for specific procedures?
Insurance coverage can be confusing. The following guidelines will help you determine service coverage and costs. Look at the Facts Don’t attempt to interpret information provided by insurance carriers if the facts provided don’t directly apply to the circumstance. Be careful of specific circumstantial exceptions. Insurance carriers provide coverage information for the most common services. […]
Insurance coverage can be confusing. The following guidelines will help you determine service coverage and costs.
Look at the Facts
Don’t attempt to interpret information provided by insurance carriers if the facts provided don’t directly apply to the circumstance. Be careful of specific circumstantial exceptions. Insurance carriers provide coverage information for the most common services. The insurance carrier should be contacted for more detail about coverage or costs for circumstances that are unique or specific to the patient.
Ask Questions
These questions can help determine whether a service or item is covered under a member’s insurance plan:
- What is the service?
- The physician or provider will describe what’s needed, often on a form with the exact name of the service or procedure. There may even be a procedure code. Use this information to help clarify coverage.
- Is the service considered preventative healthcare?
Most health plans must cover preventive services at no cost.
Unless the insurance carrier explicitly states otherwise, don’t assume services are preventative care. - Are there any unique or specific circumstances that should be considered?
Insurance carriers provide coverage information for the most common services. Unique or special circumstances can have an impact on coverage.
Final Tips
The Summary of Benefits Coverage (SBC), can be useful in determining if a particular service or item is covered by insurance. It’s important to review the Summary of Benefits and Coverage carefully.
