Frequently Asked Questions:Insurance Questions

I'm covered under my insurance and my spouse's. The deductible is less under my spouse's insurance. Can you just bill his/her insurance and not mine?

Under a provision called Coordination of Benefits, we are obligated to bill the insurance that would be considered primary for you. Any medical insurance for which you are the primary holder must be billed before any other medical insurance.

Who is responsible for getting an authorization or pre-approval for a particular service?

We will try to obtain authorization from your insurance company for services provided; however, it is ultimately your responsibility to ensure that services have been authorized or pre-approved. In some cases, insurance plans will not pay for hospital costs if patients do not pre-certify before arrival. In this case, you would be liable for that entire expense. Our filing of claims with your insurance company does not guarantee coverage or payment.

Why do I receive questionnaires from my insurance companies?

Insurance companies may need to gather additional information from policyholders before processing payments. Therefore, these questionnaires should be filled out and returned promptly to your insurance company.

What if Elmhurst Memorial Healthcare doesn’t participate with my plan?

If you are a member of a healthcare plan with which we do not participate, you may still receive services at our facility. However, these services are considered “out-of-network” and may not be covered by your health plan. You will be responsible for paying the bill in full or for any balance not paid by your health plan. As a courtesy to you, we will initially bill health plans with which we do not participate, but you will be responsible for payment if the plan does not respond promptly to our bill.

How will I know if my insurance company has paid my bill?

After your insurance company has paid its portion of your Hospital bill, we will send you a statement. This statement will indicate payments and adjustments that have been posted to your account and any balance you are required to pay. You may also receive an explanation of benefits from your insurance company.

What’s an Explanation of Benefits (EOB)?

An Explanation of Benefits is a document from your insurance company that shows how they processed your claim. It contains information such as co-pays, deductibles or non-covered services. EOBs should be kept for future reference.

I received notice that my insurance company has paid part of my bill, but I don’t understand how they calculated the payment amount. Can you help me?

If we have received any such information from your insurance company, we’ll be glad to share it with you. However, for answers to any questions about insurance payments, deductibles or co-payments, you should check with your insurance carrier.

What is a co-payment?

A co-payment is a set fee that the member pays to providers at the time service is rendered. Co-pays are applied to emergency room visits, hospital admissions, office visits, etc. The fees are usually minimal. The patient should be aware of the co-payment amounts prior to service.

What is a deductible?

Deductibles are provisions that require the member to accumulate a specific dollar amount of medical bills before benefits are paid. Once the patient has met his/her deductible, the insurance usually pays a percentage of the remaining bill or bills. The patient is liable for the unpaid percentage. Deductibles are reset annually, usually starting in January.

What is co-insurance?

Co-insurance is a form of cost sharing. After your deductible has been met, your insurance plan will begin paying a percentage of your bills, The remaining amount, known as co-insurance, is the portion due by the patient.

Why am I being asked to contact my insurance company to get payment sent to Elmhurst Memorial Healthcare? Isn’t that the Hospital’s responsibility?

Occasionally we will experience difficulty obtaining payment and will ask you to help. There are many different reasons why an insurance company will withhold payment, and the insured member can usually help resolve these problems.

How do I follow up with my insurance company?

Most insurance company ID cards have a customer service phone number on the back. Before you call, have available your insurance card, date of service, facility name, original billed amount, patient name and claim number, if applicable. Write down the name of the person you talked with at the insurance company. If the bill has not been paid, find out the anticipated payment date and ask what is needed. If the bill is not paid in the stated time frame, follow up with the insurance company again and, if necessary, request to speak to a supervisor. Other key questions you should ask the insurance company customer service representative include the following:

  • Have you received the Hospital's bill for these services?
  • Am I covered for these services?
  • When will you pay the Hospital for these services?
  • What portion of this bill will I be responsible for paying?
  • What is the status of the account? If paid, ask when and to whom.

Why didn’t my insurance pay?

One or more of the following may apply:

  • The medical attention you received was not covered under your plan.
  • Your medical situation may not have met your insurance company’s definition of “medical necessity.”
  • Often the insurance company will cite a “non-emergent condition” as a reason for not paying. Your EOB should provide more specific answers to this question.
  • The insurance information recorded at the time of service was inaccurate, incomplete or outdated.
  • You were not covered by your insurance plan at time of service.
  • Your primary care physician did not process a referral for the services, or an authorization was not obtained prior to the services being rendered.
  • Service received was from a physician/facility outside your plan’s network.

What do I do if I disagree with how much my insurance company has paid on my bill?

If you have questions regarding the payment, call your insurance company for an explanation. If the insurance company finds that an error was made, note the information and whom you talked with at the insurance company. Request an anticipated payment date and ask if they need anything to complete processing. If the insurance company feels the bill was paid correctly and you still disagree, find out from the insurance company what you need to do to file an “appeal” with them. Filing an appeal will not guarantee that the insurance company will pay more on your bill, but the claim will be reviewed for reconsideration.

Even though I gave my medical insurance, I was later asked for my automobile insurance because my injury was due to an automobile accident. My medical insurance will cover the bill. Why is any other insurance needed?

When we bill your medical insurance for treatment related to an accident, the carrier will want to know if there is any other insurance that may be liable for the bill. For Medicare recipients, this is a requirement to bill Medicare. If we cannot provide the information at the time of billing, the claim may be delayed, or even denied, until the information is given.

Why do I get a bill when workers' compensation or automobile insurance should pay for the services provided?

To ensure that your charges get filed to the appropriate payor, please be sure to provide the workers' compensation or automobile insurance claim number when you register. You must complete your workers' compensation or automobile insurance company's required paperwork for your claim to be processed.

Will the Hospital bill my workers' compensation claims for me?

Yes, we will bill workers' compensation insurance if you provide the correct information.

Elmhurst Memorial Healthcare Network

This site is part of the Elmhurst Memorial Healthcare network of Web sites, which covers a variety of topics using the same philosophy: When it comes to medical care, we know that you have a lot of options. And we want you to know that you're more than a patient to us. You're an individual. We would appreciate the opportunity to provide you with state-of-the-art medical care and down-to-earth, personalized attention.

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