Insurance Company Letter of Determination
You’ve done it all now; submitted the Letter and Application, followed up with your insurer, provided any additional requested information, and ultimately insisted on a timely response to your claim. Then the letter from your insurer arrives with its determination. You’re probably biting your nails at this point, but because of the enormous amount of hard work, dedication and attention to detail on your part, you’ve already maximized your probability of success by doing it right the first time.
Scenario 1: Your Insurance Coverage Was Approved!!
Congratulations!! Now doesn’t all that tedious, annoying and just plain hard work finally seem worth it? What you once thought of as an elusive, or even impossible dream is now literally in your hands. You and we now have the tools, and the ability, to significantly change your life. So celebrate your victory, and don’t forget to thank everyone who helped and supported you through this process.
But before scheduling that all-important date for surgery, one more essential piece of information is needed: Exactly how much of the hospital, doctor and post-surgical costs has your insurer agreed to cover? Many bariatric surgical patients, in their excitement, forget to ask this question before rushing into the operating room, only to later discover significant, and unexpected, costs that they are ultimately responsible for.
"Is it really that important?" you ask. "I’ve finally got the insurance coverage I’ve been fighting for, right here, in writing. The approval letter says they’ll cover the procedure. What’s the problem?"
The problem is that insurers vary widely in the terms of their coverage. HMO’s, PPO’s (Preferred Provider Organizations) and private insurers have separate and distinct deductibles for hospital and doctor expenses. Your policy may provide substantially different terms of coverage depending whether you seek medical services "in or out of network." Policies vary with respect to coverage for any "complications" or "follow up care." In addition, if you selected among various co-payment options, you may have "customized" the terms of your coverage at the time you initially contracted with your insurer.
To insure clarity, not you need to get a letter from the Customer Service Department of your insurer specifying the exact level of coverage that it has approved. That way, there are no surprises, and once again, you’ve got your insurer locked into its obligation by getting it in writing.
For those of you who got an Approval Letter and a Letter Specifying the Level of Coverage, you’re set. Good luck! Make that appointment for your surgery date. However, if you opened that all-important letter of determination from your insurer, and it read Your Insurance Coverage Was Denied, you have more work to do.
more on Insurance Company Letter of Determination.
*TRICARE patients with authorization don't need a prepayment.
Copyright 2005
Professor Rudolf Weiner, MD
About Us / Contact Us
|
Terms of Use & Privacy
Policy |
by OBGYN.net