Frequently Asked
Health Insurance Questions
Below you will find the
most frequently asked health insurance questions and
their answers. If you have additional health
insurance questions, please call one of our helpful
Customer Service Representatives.
What is the Accidental Medical Expense (AME) rider?
The Accident Medical Expense rider provides benefits
for injury due to a covered accident. AME benefits
are administered per injury/accident, instead of per
calendar year. After AME benefits are paid, your
annual health insurance deductible, coinsurance and
emergency room copayment (if appropriate) will
apply.
What is the Doctor's Office
Copayment (DOC) option?
The Doctor's Office Copayment Option is an optional
benefit that provides 100% coverage for all covered
reasonable and customary charges for an office visit
to any physician after a copayment. Copayments do
not apply toward satisfying the deductible or
out-of-pocket maximums.
What is a Maternity rider?
A Maternity rider is an amendment to a medical
policy that provides coverage for normal childbirth.
Am I covered when I go out
of the United States?
Unless specifically excluded by your contract, you
are covered for the benefits listed in your health
insurance policy. All health insurance policy
provisions apply, including medical necessity and
reasonable and customary.
What is a Special Exception
Rider (SER)?
A Special Exception Rider excludes health
insurance coverage for a specific medical condition
for an individual family member. These riders are
generally put on health insurance policies due to
pre-existing conditions, and exclude benefits for
any diagnostic services or treatment for that
condition for the named family member.
What is a Special Class
Premium (SCP)?
A Special Class Premium is an additional premium
amount you pay for your health insurance policy due
to a medical condition you might have (for instance,
high blood pressure).
What is a non-smoker
discount?
A non-smoker discount is a reduction in the health
insurance premium amount for our policyholders who
lead a healthier lifestyle by not using tobacco
products.
What is a deductible?
A health insurance deductible is the amount of
covered expense you must incur and pay each calendar
year before we will pay for covered medical
expenses. This is for each individual, each calendar
year. Expenses that are not covered by your health
insurance policy will not be applied to your
deductible.
When does my calendar year
deductible start over?
The calendar year begins January 1st and ends
December 31st each year.
What is coinsurance?
Coinsurance (also known as Rate of Payment) is the
percentage of covered expense you are responsible
for after you have met your deductible. For example,
if your coinsurance is 20% up to $5000, Insurer will
pay benefits at 80% of covered expenses up to $5000.
Then the insurer pays 100% of your covered charges,
up to the policy maximum. You are responsible for
the 20% amount that the insurer does not pay.
What is a copayment?
A copayment is the amount you pay for each
prescription drug or PPO physician office visit.
What is individual
out-of-pocket expense?
Individual out-of-pocket expense is your deductible
and coinsurance added together. In other words, it
is the maximum you will have to pay — per person,
per calendar year — in deductibles and coinsurance.
What is family
out-of-pocket expense?
Family out-of-pocket expense is your deductible and
coinsurance added together, for your whole family.
In other words, it is the maximum you will have to
pay per person, per calendar year, no matter how
many members of your family need health insurance
benefits.
What is reasonable and
customary?
Reasonable and customary (R&C) is the dollar amount
allowed for a particular service. The reasonable and
customary amount for charges is determined by your
insurer using your geographic area.
What do I do if my
physician or hospital is billing me for the amount
not covered as over the reasonable and customary
amount?
There is a specific reasonable and customary amount
allowed in your geographic area, and this is the
amount allowed by your policy. Anything over the
reasonable and customary amount would be your
responsibility.
What is preauthorization?
Preauthorization is when we are notified in advance
of a surgery or hospital stay, and is required for
most policies. The requirements can differ from
policy to policy, but the purpose of
preauthorization is to determine if a
hospitalization or surgery is medically necessary,
and how many days of hospitalization are warranted.
Your health insurance ID card shows the
preauthorization telephone number, and a full
listing of which services require preauthorization
can be found in your health insurance policy. Please
follow the preauthorization procedure in order to
maximize your benefits.
What is a predetermination?
A predetermination of benefits is a written request
for verification of benefits. The insurer reviews
these requests based on policy provisions, and send
an explanation of your potential health insurance
benefits. You may request a predetermination before
your medical procedure, although a predetermination
of benefits is generally not necessary.
Does my surgery/hospital
stay need preauthorization?
In most cases, preauthorization is a requirement for
services listed in your health insurance policy.
Please review your health insurance policy for
details.
How do I get my
surgery/hospital stay preauthorized?
Your health insurance ID card shows the
preauthorization telephone number, and a full
listing of which services require preauthorization
can be found in your health insurance policy. Please
follow the preauthorization procedure in order to
maximize your benefits.
How am I notified whether
or not my surgery/hospital stay is preauthorized?
Your preauthorization vendor will send you a
telegram that will explain if the procedure and/or
hospital stay is approved or denied. If you are
being hospitalized, the specific number of days
approved will also be provided.
How long do I have to
submit a bill/claim?
Please submit the claim as soon as you can. The
insurer cannot consider any claim received more than
15 months after the date of service.
How do I get a claim form
for my prescriptions?
Usually, the pharmacy will submit prescription
claims for you. Otherwise, to order claim forms,
simply contact the number on your prescription ID
card.
Where do I send claims?
Refer to the back of your health insurance ID card
for claims submission information.
How long does it take to
process a claim?
The amount of time it takes to process a claim
depends on the information submitted. In general,
you should receive an Explanation of Benefits within
3-4 weeks. If additional information is required to
process a claim, we will notify you, and the claim
could take longer to process.
How do I appeal a claim
denial?
If you believe your claim has been processed
incorrectly, please contact your insurer's Customer
Services Department. If you do not agree with the
denial of a claim, send an appeal in writing to the
insurer. Note any extenuating details, include
any documentation pertaining to the appeal, and keep
a copy for your records.
My physical
therapy/chiropractic claim was denied as maintenance
care. What does that mean?
Maintenance care means that the care that you are
receiving is no longer improving your medical
condition.
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Network
Questions
Below you will find the
most frequently asked health insurance questions in
regard to provider networks. If you have additional
health insurance questions about networks, call one
of your helpful Customer Service Representatives.
What is the Network Option?
This option utilizes a network, which is comprised
of a large number of participating hospitals and
physicians. The providers in this network have
agreed to reduce the amount they charge for services
provided to our policyholders. Network availability
may vary depending on the area in which you live.
Who is my vendor?
What is the name of my Network?
This information is printed on your health insurance
ID card, along with a telephone number for you to
contact the network vendor for your policy.
Which physicians and
hospitals are members of my Network?
How can I find out if my physician is a member of
my Network?
At the time you received your health insurance
policy, you may have received a directory of
physicians and hospitals in your network. If you
would like an updated list, please contact your
network vendor. You may also contact your provider's
office and ask if the physician is a member of the
network (listed on your ID card). Always verify
whether your provider is a member of the network in
order to maximize your health insurance benefits.
How can I get an updated
Network directory?
Please contact your network vendor. Always verify
whether your provider is a member of the network in
order to maximize your health insurance benefits.
How do I contact my vendor?
A telephone number for your network vendor is
printed on your health insurance ID card.
Why are my claims sent to
the Network vendor first?
The network vendor determines the discounts that are
applied to your bills, and then forwards them to
your insurer.
My Network physician wasn't
in the office. I saw the "on call" physician. Will
this be paid as a Network claim?
If the physician you saw is a member of your
network, we will consider the charges at the network
rate of payment. If the physician you saw is not a
member of your network, we will consider the charges
at the non-participating provider rate of payment.
The clinic was a Network
provider. Why wasn't the physician paid as a Network
provider?
Each physician contracts individually with the
network. If the physician you saw is not a member of
your network, we will consider the charges at the
non-participating provider rate of payment.
I was on vacation and had
to see a physician. Will you pay my claim at the
Network rate?
If the physician you saw is a member of your
network, we will consider the charges at the network
rate of payment. If the physician you saw is not a
member of your network, we will consider the charges
at the non-participating provider rate of payment.
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