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Visitors Health Insurance - Claims Procedure within PPO network
A: You are free to visit any provider you wish in all the plans. There is no restriction that you can't visit certain providers or that you can visit only certain providers.
Most insurance companies whose products we offer have a provider network (PPO network). PPO stands for Preferred Provider Organization and has the directory of providers that have a relationship with the PPO provider. And the link to the provider network is provided next to that product's details. And if you visit any provider such as a doctor/hospital in that network, they have a Network Negotiated Charge (NNC) between them (unless an exception is noted for a particular plan). Hence, the providers will charge only the amount they have agreed to with the insurance company.
In other words, visiting a provider in the PPO network has benefits and it is not a restriction. Moreover, there are many providers in most parts of the U.S., and you should not have any difficulty searching for a provider.
If you visit any provider outside the network, there may be a reduction in benefits.
Currently, all visitors insurance plans that participate in the PPO network provide network negotiated fees within the PPO network.
Q: If I get sick, do I have to pay the doctor/hospital up front and then get reimbursed or will the doctor/hospital directly bill the insurance?
A: When you buy insurance from a U.S. insurance company, you would receive the medical insurance card that will have your name, policy number, group number if applicable, insurance company's usually toll-free telephone number and the address where the claims can be submitted. When you get sick, visit the doctor with that card, and most of the times, the receptionist will take that card, call the insurance company and verify the coverage. The doctor's office has all the details to bill the insurance company directly, and you would pay the deductible if you have not fulfilled the amount yet.
In fact, most of the plans are PPO plans and have providers all across the United States that participate in the PPO network. When you go to the doctors in the network, please mention that you have the a particular PPO Network plan (such as Coventry, First Health, PHCS, MultiPlan, ChoiceCare etc.), as the doctor sometimes may not be aware of the insurance plan name (such as Visitors Care, Atlas America, Liaison International etc.), or the administrator name (IMG, Seven Corners, HCCMIS etc.) or the insurance carrier (Sirius, Lloyds, Nationwide, Chartis etc.).
Also, most of the times, hospitals will directly bill the insurance company. But sometimes individual doctor's offices may not be comfortable with billing the insurance company directly, they may demand payment from you upon receipt of treatment. In that case, you would get the itemized bill from the doctor for submitting them with the claim form to the insurance company.
Q: Do I have to file for a claim or will the provider bill the insurance company directly? If I went to the provider within the PPO network, why do I have to file the claim form?
A: While it is true that the claim form is widely used for reimbursement of the prepaid medical expenses, that is not the only purpose of the claim form.
Even if the provider bills the insurance company directly, the insurance company can not make payment until they have medical records from the provider to make sure that it is an eligible expense. However, as the medical records are confidential in the U.S. under federal law called HIPAA, the provider can not release them until they have a written authorization from you. The claim form serves that purpose as well.
When a U.S. resident visits the provider using a domestic health insurance, the insurance company already has a lot of information about the insured. However, such information is not available in case of the short term visitor. The insurance company needs to get additional information about you, your illness/injury/accident in your words, and also collect information about your international travel dates, make sure of your identity etc. in order to make sure that you are indeed eligible for the insurance plan and for the benefits sought. The claim form provides all this information.
In other words, the claim form serves many purposes.
Therefore, even if the provider agrees to bill the insurance company directly, you should still file a Claim Form to expedite the claim process. If you don't file the form, the insurance company will send you that form anyway once they receive the bills from the provider.
Q: When I went to the participating provider in the network. They still refused to accept the insurance and bill directly. I paid $140 up front out of my pocket. However, when I submitted the claim to the insurance company, I was covered only for $110 and I was told that the amount considered is the network negotiated fee for that service. How do I recover the balance of $30?
A: When you visit the providers in the network, they should be billing the insurance company directly. Therefore, this kind of scenario may not happen often. Anyway, if the provider is in the network, and if they were supposed to charge you only $110 for a particular visit, they should have charged you only $110 to begin with. It will be your responsibility to collect the balance of $30 from that provider. Please show the explanation of benefits to the provider.
Q: How do I find the participating providers for a particular visitors health insurance?
A: Please visit our Current Clients area.
Select the plan you are interested in. And select the task as 'Provider Directory (PPO Network' and click on 'Submit').
Click on the button 'Search Providers' inside USA. Some plans also have the provider network search outside USA as well.
Enter your criteria to search for the particular providers. You can use various criteria such as the zip code, city/state, type of facility (doctor, hospital, urgent care etc.), the specialization of the provider etc.
You can search for the participating provider for a particular plan, even before you buy the insurance.
A: The concept of a PPO network exists primarily in the U.S. only. Many countries that have the concept of socialized medicine (Canada, most countries in Europe, Australia etc.) do not generally have the PPO network concept. Therefore, the situation remains the same no matter which insurance you purchase. That is because it is not dependent upon the particular plan, but it is according to the overall healthcare system of the particular country.
When you are traveling outside the U.S., there is really no way to know which providers would bill the insurance company directly and which ones would not. However, in any case, the insurance company is always willing to work with the provider for direct payment. But it is still up to the provider.
For big expenses in developed countries, the hospitals may be willing to work with the insurance company. But in other cases, you may just end up paying out of your pocket and file for reimbursement.
Even those travel medical insurance plans that have the provider directory list, that does not necessarily mean that those providers are in the PPO network and will work with the insurance company directly. In many cases, the list is simply a directory like the yellow pages. You could as well find the same information by searching online anywhere, asking the friends or others.
Anyway, you generally don't have to worry about the reduced coverage out of network because there is no network. The covered amounts would be the same no matter where you seek treatment.
Disclaimer: The information within this article is intended as a broad summary of benefits and services and is meant for informational purposes only. The information does not describe all scenarios, coverages or exclusions of any insurance plan. The benefits and services of an insurance plan are subject to change. This is not your policy/certificate of insurance. If there is any discrepancy between the information in this article and the language of your policy/certificate wording, the language of the policy/certificate wording will prevail.