Approvals from Your Insurer
Your Spectrum Health provider will decide which procedures, tests and other consultations you may need. However, many health plans require pre-certification and sometimes predetermination of medical necessity prior to care being rendered. In addition, some services may not be a covered benefit for some plans. Investigating coverage requirements and limits can take up to six weeks, and some services require pre-certification staff to supply photos and medical necessity information to your insurance company.
For example, services that may require pre-certification include outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies.
Patients are responsible for knowing the pre-certification requirements of their health plans. Spectrum Health highly recommends that you contact your insurance company to determine benefits and coverage for the location at which you plan to be seen.
Managed care plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) may deny or reduce benefits if care is obtained outside of the established network or authorization of the plan.
Patients' plans that require prior authorization or pre-certification may provide only a reduced insurance payment if not previously authorized. In such cases, the patient will be financially responsible for more — possibly all — of the provided services.
A pre-service deposit may be required for nonauthorized visits.
To avoid paying a pre-service deposit or experiencing either denial of payment or a reduction of benefits, Spectrum Health highly recommends you contact your insurance carrier prior to services to determine plan requirements or limitations to receiving care at the Spectrum Health site at which you will receive services.