You need to be aware that your insurance policy is a contract. If you do not have a copy of your policy in its entirety, obtain one as soon as possible. We recommend that you read and understand your policy and if you have any questions regarding your coverage, contact the insurance company directly or your Human Resources Department for more information.
There are a number of different policies written (Indemnity, Preferred Provider Organization, Point of Service, Health Management Organization) and you need to know what your coverage is (annual deductible, co-insurance, maximum out of pocket expenses, lifetime maximum etc…). In some plans you can have in and out of network benefits known as a swing plan.
We have a contract with Medicare and currently do work with many other carriers on an ‘out of network’ basis. In some cases, if your insurance carrier cannot provide necessary medical care within the network, the carrier will grant the policyholder a waiver (sometimes referred to as a ‘Network Clinical Gap Exception’) to go outside the network for treatment. The medical claim is then submitted and processed as if the policyholder stayed inside the network.
We also work with Industrial Carriers. We feel the sooner the injured worker is able to return to work the happier everyone involved will be, especially the injured worker. If you have an out-of-state Workers Compensation claim and are interested in having one of our physicians evaluate your condition, please contact our Billing Department with your Workers Compensation information (i.e. claim number, adjustor’s name, phone number and extension, if applicable). We will be happy to contact your Claim Adjustor to initiate prior authorization for your treatment.
Each state has its own laws and regulations governing all types of insurance. You need to check with your State Insurance Department if you have any questions regarding your carrier. The Self-Insured Employer’s responsibilities are different than your general group policy with a small business. Your State Insurance Department enforces the laws, as well as providing the public with information about insurance.
