If a patient is about to undergo a medical procedure, it is important to know what is and is not covered by his insurance. Whether you are the patient or the administrative staff who has to verify insurance benefits, it's critical for all involved to find out beforehand what the insurance company will and will not pay for. A patient might have changed jobs or health plans, may be in a waiting period or upgraded services under his current plan. Whatever the reason or the need for verifying insurance, knowing what is covered is important for the patient and the caregiver.
Obtain demographics and insurance numbers. Before insurance benefits can be verified, get the patient's name, insurance company, the effective date, plan or group number. This basic information ensures the confirmation of the right plan and individual.
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Contact the insurance provider. Check the effective dates and coverage period. Use the patient's health insurance identification (ID) card or number to confirm the policy term with the insurance company. By checking the policy term, it ensures medical coverage for the patient is current and has not lapsed.
Assess the deductibles, co-payments and coinsurance, if any. Depending on the type of plan, whether it's an Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO), confirm the patient's co-pay, if any. If it's an HMO, most often the patient has a small co-pay. With a PPO, factors such as coinsurance and out-of-pocket deductibles may affect payments; the patient may need to pay for the visit up front and get reimbursed later or pay a portion of the fee.
Ask about preexisting conditions exclusions. This question applies more for PPO's than HMO's. HMO's may not impose a preexisting condition exclusion upon the coverage. The most they can impose is a waiting period that cannot exceed two months. PPO's can institute preexisting conditions exclusions that last up to 18 months
Inquire about policy limits and coverage. Some policies provide 100 percent coverage for visits such as well care visits, annual dental cleanings or other preventative maintenance visits. Other procedures, although covered by the insurance policy, may have caps. In other words, the insurance company will only pay up to a certain amount for things such as dental crowns or other surgical procedures. It is important to know beforehand how the insurance company will respond to each procedure.
Remain in constant communication with the insurance company and the insured to make sure everyone knows what the insurance company is willing to pay.