IT PAYS TO UNDERSTAND YOUR INSURANCE COVERAGE

Your insurance policy lists a package of medical benefits such as treatments, tests, and drugs that the company agrees to cover at a specified rate and manner.  These are called "covered services".

Your policy also lists the kinds of services that are not covered by your insurance company.  It is your responsibility to pay the cost of "non-covered services."  Keep in mind that a medical necessity is not the same as a medical benefit.  A medical necessity is something that your doctor has decided is necessary.  A medical benefit is something that your insurance plan has agreed to cover.  In some cases your doctor might recommend and order medical care that is not covered by your insurance policy.

There are so many different insurance plans, even within the same company, that it is impossible for your doctor to know the specific details of each plan.  By understanding your insurance coverage, you can work with your doctor in making informed choices on medical care that coordinates as much as possible with your covered services.

·        Take the time to read your insurance policy.  It's better to know what your insurance company will pay for before you receive a service or fill a prescription.  Some kinds of care may require "preauthorization".

·        If you still have questions about your coverage, call your insurance company and ask a representative to explain it.

·        Remember that your insurance company, not your doctor, makes decisions about what will be paid for and what will not.

If your insurance company denies a claim and will not pay, you do have the right to appeal.  Before you make that decision review your policy and familiarize yourself with the company's appeal process.  But remember, the doctor orders what he feels is necessary for your care and the insurance company is not obliged to pay unless it is a covered service.