You should talk to the insurance company and your HR person (who will know the specifics of your particular plan). But my read on it is:
1. The surgery is a procedure that UHC covers, so when you have it and submit the bill, they won't reject the claim.
2. When you have the surgery, UHC will pay for all the allowable charges on the bill, and won't pay for any unallowable charges.
It's that "allowable charge" thing--CYA for them--that you'll want to know the details about. Under insurance plans I've had, here are some reasons a charge might be unallowable:
1. Exceeds a benefit. (E.g., 4 hospital days instead of 2--in which case they'd pay for 2, I'd pay for 2).
2. Exceeds the generally accepted market price for a service. (E.g., $1000 instead of $800--in which case they'd pay the $800, I'd pay $200).
3. Paperwork wasn't filled out properly beforehand. (E.g., improper or no referrals to a specialist).
4. It's not a benefit anymore by the time the service actually is provided. (E.g., the employer renewed the policy and dropped that coverage).
5. Related to #3, it's a service that has to be deemed medically necessary in order to be covered. (E.g., chemotherapy is covered, but not if what I'm diagnosed with is an ulcer). This one can be especially tricky because some insurance companies override doctors and patients more often than others on what is "medically necessary," usually for $-saving reasons.
1. The surgery is a procedure that UHC covers, so when you have it and submit the bill, they won't reject the claim.
2. When you have the surgery, UHC will pay for all the allowable charges on the bill, and won't pay for any unallowable charges.
It's that "allowable charge" thing--CYA for them--that you'll want to know the details about. Under insurance plans I've had, here are some reasons a charge might be unallowable:
1. Exceeds a benefit. (E.g., 4 hospital days instead of 2--in which case they'd pay for 2, I'd pay for 2).
2. Exceeds the generally accepted market price for a service. (E.g., $1000 instead of $800--in which case they'd pay the $800, I'd pay $200).
3. Paperwork wasn't filled out properly beforehand. (E.g., improper or no referrals to a specialist).
4. It's not a benefit anymore by the time the service actually is provided. (E.g., the employer renewed the policy and dropped that coverage).
5. Related to #3, it's a service that has to be deemed medically necessary in order to be covered. (E.g., chemotherapy is covered, but not if what I'm diagnosed with is an ulcer). This one can be especially tricky because some insurance companies override doctors and patients more often than others on what is "medically necessary," usually for $-saving reasons.
Reply
Leave a comment