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The following materials are for informational purposes only and not for the purpose of providing legal advice. Please contact your attorney for clarification of your rights and legal advice. Please refer to Terms and Conditions for Warranty Disclaimer.
Benefit Verification Guidelines
We understand that dealing with insurance companies regarding your infertility coverage might be a little intimidating at first glance. But in order for you to make informed decisions about your infertility diagnostic testing and treatment, you must gather information on your insurance benefits.
To verify insurance benefits by phone, please refer to the customer service phone number printed on your insurance card.
Before you call your insurance company, review the health insurance benefit booklet provided by your employer, and copy any sections that pertain to infertility benefits as well as any benefit exclusions. Our financial staff will be happy to review the document with you in order to assist you in interpreting your coverage.
Specifically ask for benefits relating to infertility. A list of Billing Codes for Infertility Diagnosis and Treatment is provided with this document for your convenience.You should provide both the diagnosis code (ICD-10 code) and the procedure code (CPT code) when requesting verification of coverage. Some procedure codes that typically are covered may be denied if the diagnosis is infertility. This is important!
- Simply having insurance benefit does not mean you are eligible to be reimbursed for the benefit. Ask if there are any specific medical criteria that must be met in order to be eligible for infertility benefits, e.g. Must you undergo lesser treatments (IUI) before proceeding to advanced treatments (IVF/ICSI)? Must you have a specific documented diagnosis?Will IVF/ICSI only be paid for certain diagnoses? Is there any limit, dollar or number, on treatment cycles? Are there any factors that would cause denial of benefits, e.g. prior failed treatment, prior sterilization, etc.?
- Document the name of the customer service representative giving you the information, the department in which he/she works, and the phone number you called. Also ask for a reference number for the phone call.
- Always document the date and time of the phone call as well as what was discussed. Your insurance company also will be documenting the content of the call, so be accurate and comprehensive with your own documentation.Repeat the information you are given to be sure you are accurate.
- If possible, request written confirmation of any benefits described and ask how long it will take to receive this confirmation. If your insurance company advises you to submit a request for predetermination of benefits, ask for the address and fax number where you can send your written request for benefit verification. Be advised that your insurance company may take up to 6 weeks to respond to your request, and the response you receive still may be vague. If your insurance is provided through an employer, you may need to contact your Human Resources department to assist you further in defining your insurance benefits.
- Some insurance companies may require a letter of medical necessity for predetermination of benefits prior to services being rendered in order for your benefits to be paid. Make sure you obtain the address and fax number where this letter must be sent, and ask how long it will take for a response. Keep in mind that any response to such a letter still will not be a guarantee of payment. Your insurance company always reserves its right to deny payment until after an insurance claim is submitted and reviewed.
Important facts you must know
About Health Insurance
- No weather forecaster can guarantee it will rain tomorrow. Family Fertility Center and its staff can never guarantee payment of your claims by your insurance company.
- Please refrain from asking us to change your diagnosis code so your claim will be paid by your insurance company. That constitutes as insurance fraud. Family Fertility Center never bills fraudulently.
- Simply having insurance benefit does not guarantee you are eligible to be reimbursed for the benefit. Your insurance company always reserves its right to determine eligibility at the time a claim is submitted and to deny payment if eligibility requirements are not met at that time.
- Your insurance company makes no guarantee the information given by its representative is factual, complete or accurate.
- Your insurance company uses very specific guidelines to determine the extent of your infertility benefits and how your claims will be processed. Although hundreds of representatives are employed to advise you of your plan’s specific infertility benefits and any referral/ preauthorization requirements, there is absolutely no guarantee the information given by any representative is factual, complete or accurate. To be fair, interpreting the writing in an insurance policy is at best an arduous task. The language is typically ambiguous and rarely answers a question on point. Often there are conflicting statements within a single policy, creating more than one version of interpretation. But if you rely on the information given by a representative of your insurance company and undergo infertility diagnosis and treatment which later turns out to be non-covered services, your only recourse to hold your insurance company accountable for its mistake is through legal action.
- Investigate your benefits thoroughly and obtain written verification.
- We urge you to investigate your insurance plan thoroughly and strongly recommend you to obtain written verification of your infertility benefits and any referral/preauthorization requirements well in advance of services being rendered in order to make decisions about any out-of-pocket expenses you may incur. Bear in mind even with a written verification, some important information may still be not clearly explained or omitted unintentionally. In the event claims are denied — even though you were told the services were covered, having written documentation at least will show you acted in “good faith” that the information provided by your insurance company was valid and reliable.
- Ultimately, there is no guarantee of payment by your insurance company.
- No matter what your insurance company tells you or your doctor’s office about your benefits and despite your due diligence to obtain all the written verification, required referrals, pre-authorizations, or pre-certifications in an attempt to ensure reimbursement, you still have no guarantee of payment. So, despite all good efforts by you and your physician’s office, you still could be held responsible for all charges incurred.
If treatment is covered by your insurance plan, we will submit all covered services directly to your insurance company for payment if we participate with your plan. If we do not participate with our plan and you have coverage for all or part of the recommended treatment, you must meet with our financial staff prior to services being rendered to discuss how non-covered charges will be paid.
If benefits for diagnosis and/or treatment are not covered under your insurance plan, our staff will estimate a cash price for services to be rendered which must be paid in full prior to starting your treatment cycle.
Please feel free to speak with our financial staff at any time to better understand your benefits, your out-of-pocket expenses, or your insurance coverage.
Important Information Before Changing Your Insurance
Please let us know immediately if your insurance plan is changing. Your benefits may change even though the insurance company – or insurance card — remains the same. Your employer may drop benefits, increase or decrease out-of-pocket expenses or benefit limits, or add preauthorization requirements — all of which may impact your eligibility or reimbursement. Sometimes your insurance company will not be able to access or verify your benefits until the new benefit plan is fully integrated, so your treatment may have to be placed on hold. We always encourage you to independently re-confirm your benefits prior to starting any new treatment cycle. We will be happy to assist you in this effort.
If you are changing insurances due to open enrollment, be sure to request a benefit booklet from your employer to research specific benefits and out-of-pocket expenses. Check for pre-existing condition exclusions, which may exclude treatment entirely or establish a waiting period before claims will be paid. Often benefits pertaining to infertility will not be addressed in the Covered Services section of your benefit booklet, so review the Benefit Exclusions section. Many insurance companies have eligibility requirements based on medical criteria in order to receive infertility benefits, so make sure you know if you meet those criteria. While Family Fertility Staff cannot advise you which plan to choose, we are willing to help you interpret the language specific to infertility benefits.
Approximately 70% of patients have some coverage for infertility diagnosis and/or treatment.
- Most Aetna plans
- Blue Shield Premier Blue PPO Network (if your card has a suitcase with a PPO, we participate)
- Most Capital Blue Cross plans
- CIGNA (no HMO or Medicaid plans)
- Great West Healthcare
- Amerihealth of Pennsylvania
- Keystone Health Plan Central
- Geisinger Insurance
- Valley Preferred Insurance
Schedule a Consultation
If you are experiencing a medical emergency, call 911 or go to the nearest emergency room.
We understand you may have a lot of questions. Each couple or individual has a unique set of circumstances. The most effective way to get answer for your specific situation is to have a face-to-face consultation with our physician.