- Changes in Insurance Coverage:
On occasion, health insurance companies may revise their policy which will result in an alteration or change in the medical services that it will cover. Sometimes the change in coverage is a result of a different choice of plan and this is often the result from a change in employment benefits. In either event this change can result in a limit or reduction in the amount the insurer will pay for a particular medical service or a complete elimination of coverage.
- A Lapse in Insurance Coverage:
A “lapse in coverage” means that there was a period of time during which your health insurance was not in effect. Such a lapse in coverage may be the result of a loss of employment, change in employment, change of insurer or the failure to pay the premium. Whatever the reason, any medical services received during that period will not be covered or paid by the insurance company.
Depending upon the amount of coverage offered by your health insurer, most plans will require payment by the patient of some amount for the medical service. The co-pay amount is usually determined by a percentage of the charge for the service or a set dollar amount depending on the terms of your health insurance policy
A deductible is different from a co-pay in that a deductible is a set amount of money that will have to paid out of your own pocket for medical services first before the insurance company will have to cover your medical expenses. For example, depending upon the terms of your health insurance policy, some policies require that you pay for the first $500.00 worth of qualifying medical services. Once the $500.00 threshold is met only then will your insurer begin to pay for the covered medical services. Some deductibles can be quite higher depending again upon the terms of your health insurance policy.
All major medical insurers such as United Health and Blue Cross Blue Shield have time limits in which to file a claim for payment after the delivery of the covered medical service. That is, there are a certain number of days in which a claim must be sent to the health insurer to obtain payment. If you did not promptly provide the necessary insurance information to the doctor, hospital or other medical provider your claim for payment of the medical services can not be timely filed and your insurance company will refuse payment for that reason. Although you will probably be able to appeal the decision of denial for timely filing, the doctor, hospital or other medical provider can not do so. Otherwise you will be responsible for payment of the bill. This is why it is very important for you to promptly respond to all requests for insurance information.
This is a standard form issued by most health insurers upon processing a claim. This “Explanation of Benefits” form is sent to you to inform you of how much was paid on a particular medical service and if not paid, the reason for such denial.