You may need pre-approval (sometimes called pre-authorization or prior authorization) from your health plan before you have surgery or receive certain other healthcare services. Through the pre-approval process, your health plan confirms medical necessity—in other words, that the service is appropriate for your condition. As a healthcare consumer, it is important to understand which services require pre-approval. If you receive care without first obtaining a required pre-approval, your health plan may not cover your claims. Pre-approval may be required for a variety of services, such as CT scans or MRI scans, not just for surgery. When in doubt, call your health plan to find out whether pre-approval is needed.
If you have health insurance with a HMO or PPO plan with which we do not participate, you may still receive services at our facility. However, these services are considered “out-of-network” and may not be covered. You will be responsible for paying the bill in full, or for any balance not paid by your health insurance. Check with your HMO or PPO plan to understand your policy’s limitations.
For health services related to such injuries, health insurance plans normally only pay benefits after the auto insurance or workers' compensation insurance has paid their portion. This is also required for Medicare and Medicaid. If we do not provide the accident insurance information at the time of billing, the claim will be delayed or may even be denied until the information is provided.
A deductible is the amount that you may have to pay before your health insurance pays. Many plans offered today are called High-Deductible Health Plans where the deductible can be as high as $6,450 for single coverage or $12,900 for family coverage. Once the patient has met his/her deductible, the insurance usually pays a percentage of the remaining bills. The patient is liable for the unpaid percentage. Deductibles are reset annually, usually starting in January.
Co-insurance is a form of cost sharing. After your deductible has been met, your insurance plan will begin paying a percentage of your bills. The remaining amount, known as co-insurance, is the portion due by the patient.
After your insurance company has paid its portion of your Hospital bill, we will send you a statement. This statement will indicate payments and adjustments that have been posted to your account and any balance you are required to pay. You may also receive an explanation of benefits (EOB) from your insurance company.
An Explanation of Benefits is a document from your insurance company that shows how they processed your claim. It contains information such as co-pays, deductibles or non-covered services. EOBs should be kept for future reference.