Will my health plan cover a procedure?

Sometimes a health plan will require preauthorization for a proposed treatment plan to determine whether or not it is medically necessary.

Check with your insurance plan to see whether preauthorization is required. If so, your healthcare provider will make the request in writing and submit all of the information to your insurance company. If you go to an out-of-network provider, then you will have to submit the forms yourself.

If coverage for the procedure is denied for some reason, you will have the right to appeal.

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Glossary

Full Glossary

Actuarial Value (AV)

The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual healthcare needs and the terms of your insurance policy.

Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA) – also known as the Affordable Care Act or ACA, and generally referred to as Obamacare – is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The Affordable Care Act’s main focus is on providing more Americans with access to affordable health insurance, improving the quality of healthcare and health insurance, regulating the health insurance industry, and reducing healthcare spending in the US. The law contains hundreds of different provisions that address different aspects of “the healthcare crisis” in the US.

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Will my health plan cover a procedure?