All Arizona health insurance plans have rules that must be followed. Some health insurance plans are more restrictive than others, and not knowing the rules of your plan can lead to claims not being paid. Generally speaking, HMO (Health Maintenance Organization) and EPO (Exclusive Provider Organization) plans are more restrictive than PPO (Preferred Provider Organization) plans.
The Rules:
Does your plan require that you choose a Primary Care Physician? If so, you likely are insured with an HMO plan. HMO policies also often require that a policyholder receive a pre-approved referral from the insurer before seeing a specialist. Some HMO and EPO policies are Open Access Plans that do not require a referral before scheduling a specialist visit.
Every health insurance policy will require that the policyholder receive pre-approval before receiving expensive services such as surgery or certain medications. This is known as Pre-Authorization. The provider of in-network medical services will obtain pre-authorization from the insurance company before services are rendered. If the provider is out-of-network, it is imperative that the policyholder make sure the provider has received pre-approval before going forward.
Regarding out-of-network claims (assuming your policy has out-of-network benefits) insurance companies will have a deadline in which claims must be filed. After the deadline the insurer has no responsibility to pay, and it is important to know the deadline date. If the claim is in relation to an emergency hospital admission the health insurance company likely requires that it be notified within 48 hours after admission.
At the end of the day, it is ultimately up to the policyholder to know the rules of the road, otherwise a very expensive lesson may be learned. If you have questions call your broker, call your insurance company, visit or create your online patient portal, and most importantly… keep detailed records!