You may have called an insurance company’s member services department only to be placed on hold for many minutes, if the call is answered at all.
Health-E Life Partners eliminates this frustrating experience and provides the caring, personalized service you expect.
Whatever help you need about your healthcare plan, we are here as your personal assistant to provide the best solutions.
+ • When should I use the emergency room?
This is the most important benefit to understand. Emergencies are defined as the threat of loss of life or limb. Examples of emergencies are: fainting, severe chest pain, serious burns, heavy bleeding and major trauma. Many emergency room visits are denied by insurance companies due to non-emergent use of the emergency room. When this happens, you will be responsible for the entire cost of the ER visit out of your own pocket. This cost will not go towards your out-of-pocket maximum as it is considered a penalty for improper use of the emergency room.
However, insurance companies also use the “reasonable person” standard. For example, if you believe you may be having a heart attack due to chest pain but the final diagnosis was heartburn, insurance companies will consider the presenting symptoms and process your claim accordingly. They may request additional medical records in order to determine whether the visit was a true emergency.
If your emergency room visit is denied, you may use your H.E.L.P. patient advocate to appeal your case if you believe it was a true emergency and our experts agree with you after considering your situation and medical records.
Depending on your symptoms, the emergency room should be your last option after considering all the other points of access.
If you have a life or limb-threatening situation, call 911 immediately. Never drive yourself to the ER.
+ • What are the points of access?
Depending on your insurance plan, other than an emergency, there are 4 other points of accessing medical services.
Physician Office Visits – You would normally schedule an appointment with your primary care doctor for routine checkups (preventive services) and if you have a medical condition that needs regular check-ups including prenatal care.
Telemedicine – Most insurance companies have this benefit for $0 or a small copay. It’s usually an app that you download on your phone and/or computer so that when you have a common minor illness like the flu, you can just use the app and the provider will provide a diagnosis and send the prescription (if needed) to your pharmacy. If you have someone who can pick up the prescription for you or if the pharmacy delivers, you never have to get out of bed, get dressed and wait in an urgent care facility as you can use the app in bed or at work. You can also use telemedicine for common allergies and infections.
Urgent Care – You should go to the urgent care whenever you can’t use the telemedicine benefit because your physical presence is required to take laboratory or diagnostic tests. x-rays, or put a sling on your sprained arm; or your illness is more serious. If you use the telemedicine benefit first and the provider determines that your illness is more serious, they will tell you to go to the most appropriate facility.
Mobile Urgent Care – This is an urgent care service that comes to your home and usually charge the same urgent care copay charged at an urgent care facility. So, if you’re too sick or weak to go to the nearest contracted urgent care facility, this may be the best option for you.
+ • What is a deductible??
A deductible is a lot like your car insurance deductible. This is the amount you are responsible to pay before the insurance company will pay their portion of your coinsurance. A calendar year deductible starts from your effective date until Dec. 31st of each year so it may be shorter than 12 months.
A benefit year deductible starts from the effective date of the plan to the end of the month prior to the effective date so if your employer group plan started on June 1st, the benefit year deductible will end on May 31st of the following year. Then it starts again on June 1st. If you were eligible for benefits later than June 1st, your benefit year deductible will still end on May 31st.
In most cases, the deductible applies to higher cost items like hospitalization. Depending on the cost of the medical service, you may not have to satisfy the entire deductible. For example, if you have a $2,000 deductible and the medical service costs $750, you will only be responsible for the $750. This amount is then subtracted from your deductible so that next time, your deductible will only be $1,250. If you are then hospitalized, you will be responsible for $1,250 up front and the rest will be billed at your coinsurance, up to your out-of-pocket maximum.
+ • What is a coinsurance??
A coinsurance is the amount you are responsible to pay after your deductible has been satisfied. This may be anywhere from 0% - 50% of the contracted provider’s bill. Your deductible, coinsurance and copays, all roll up to the out of pocket maximum so that you will not be responsible for bills once you’ve reached your out-of-pocket maximum; unless you use non-contracted/out-of-network providers.
+ • What is an out-of-pocket maximum?
This is your safety net. Out-of-pocket maximum is the most you would pay in any calendar or benefit year for all the covered services you use. Your copays, deductible and coinsurance all add up to your out-of-pocket maximum. Once your medical bills add up to this amount, you will no longer pay for any covered service for the rest of that year, including prescriptions.
Now, out-of-network out-of-pocket maximums may work differently. Even when you have an out-of-network out-of-pocket maximum, you may still be responsible for any costs above the insurance company’s payment to that non-contracted provider.
+ • What is a non-contracted provider?
Non-contracted providers do not have an arrangement with the insurance company, so they will bill you as if you don’t have any insurance. The insurance company will then only pay their portion using the discounted rate they would normally pay a contracted provider. The result is you would pay the difference between the non-contracted provider’s bill and the insurance company payment. For example, if you go to a non-contracted doctor for an office visit and the bill is $150, and you’ve already met the out-of-network deductible, the insurance company may pay only $50 of that bill leaving you to pay the balance of $100 even though your benefit says “After your deductible, your coinsurance is 50%”. Therefore, because the insurance company does not have a contract with that provider, you’ll pay the additional $25 between of what you thought would only be $75.
If the bill is a financial difficulty, you may use your H.E.L.P. patient advocate to negotiate the bill for you.
+ • What is prior authorization?
Insurance companies normally need to authorize certain services in order for you to receive the benefit. Medical professionals such as registered nurses and/or the insurance company’s medical director will review the request for medical necessity. Medically necessary services does not necessarily mean that your insurance company will pay for all or some of the service. Prior authorization request services are approved because they agree with your provider that you need the medical service for the diagnosis/symptoms presented.
Prior authorizations have a negative connotation due to the process involved. However, it could also mean that your provider is recommending a medical service that you don’t need and the insurance company’s medical department will determine that. It’s like a second opinion. Sometimes, the insurance company may recommend or suggest a more cost-effective medical service.
However, if you and your provider believe that the insurance company made an adverse decision, you may use your H.E.L.P. patient advocate to objectively understand the situation or fight for your cause.
+ • Any other questions or for additional information?
Please contact H.E.L.P. at 1-833-907-4357 (HELP). We believe we can answer 90% of your benefit questions; and we will find out and get back to you for the other 10%.
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Address : P.O. Box 36775
Las Vegas, NV 89133
Phone : 1-833-907-4357
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Health-E Life Partners is a patient advocacy group and may include medical information on our printed material or website to educate our clients. We do not intend to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. You should never delay seeking medical advice, disregard medical advice or discontinue medical treatment because of information on our website. If you think you may have a medical emergency, call your doctor, go the emergency department, or call 911 immediately. Health-E Life Partners does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned in our written materials or website. All content found in our printed materials or website including: text, images, audio or other formats were created for informational purposes only. Links to educational content not created by Health-E Life Partners are taken at your own risk. Health-E Life Partners is not responsible for the claims of external websites and educational companies.