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Mended Little HeartGuide

Diagnosis 3 In The In-Network and Out-of-Network Providers Some insurance policies specify which facilities and providers they consider to be in-network and out-ofnetwork. You may receive less coverage (or no coverage at all) if you choose to go to an out-ofnetwork provider. Ask your insurance company for a list of in-network providers and find out about your coverage at out-of-network providers. Some insurers require referrals from your child’s primary care physician for specialty services or out-of-network providers. It’s your responsibility to understand these requirements. If you choose to go out-of-network, you may need to work with the hospital to find out whether they will accept what the insurance company is willing to pay. If not, you could get stuck paying the difference between what the insurance company will pay and what the hospital charges. Keep asking until you get a clear idea of how much you might owe. Prior Authorization Requirements Some policies require prior authorization for hospital admissions, specialty appointments or procedures. Most hospitals have staff members who will contact the insurance company on your behalf to get this authorization. Ask your child’s health care providers if they will be making those calls or if you are expected to. Medication Coverage Many insurance companies have a separate process for medication coverage. You may have a different card that you will need to show at the pharmacy. Pharmacists can assist you in figuring out which medications are covered, at what cost and whether any prior authorization is required. They may also be knowledgeable about drug assistance programs if your medication is not covered. Denial Appeals If you find yourself with a bill that you did not expect or receive a notice of a denied insurance claim, contact your insurance company. Before calling, review your written policy information so that you understand your plan’s coverage. Ask the insurance company to clarify the reason for denial. Your health care provider may need to re-submit the claim or you may need to file an appeal. Check your policy or call your insurance provider to find out what the appeals process is for your plan. You may need a letter of support from your health care provider. A resource for appeals, “Your Guide to the Appeals Process,” is available at PatientAdvocate.org. Coverage After Age 18 If you are worried about having insurance coverage for your child once they turn 18, you should begin to explore options early. If you have a private insurance policy, call the number on the card and ask how long children can remain on their parents’ policy. Current rules allow children to stay on parental policies until they are 26. This may change, however, and does not happen automatically. Most policies allow kids to stay on their parents’ insurance while they are in school. Call your insurance company to find out what your plan allows. 1 General Information 2 Prenatal Hospital 4 Living With CHD 5 Forms 25


Mended Little HeartGuide
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