Will my Procedure Be Covered?

Before you schedule a procedure, it’s normal to want clarity.

You don’t want surprises. You don’t want assumptions. You just want to know where you stand.

The good news is that most medically necessary procedures are covered under both Original Medicare and Marketplace health insurance plans. Here's how to check if a certain procedure is covered.

1) Review your Summary of Benefits.

This document outlines the types of services your plan covers and how much each procedure will cost.

Different sections talk about hospital stays, outpatient procedures, diagnostic testing, surgeries, dental, vision, hearing, and more. If you want even more detail, you can review your plan’s Evidence of Coverage document. That document goes even deeper and explains the rules, requirements, and limitations tied to specific services.

If you’re not sure where to find either document, log into your member portal, search for your plan's information on the carrier website,  or call the customer service number on the back of your insurance card and ask them to send you copies. Having both documents in front of you makes it much easier to determine whether a procedure falls within your plan’s coverage rules.

2) Ask Member Services

Call the number on the back of your card and ask if your procedure will be covered. You can also ask whether pre-authorization or any additional steps are required. While not necessary, you could ask your medical provider for the billing codes they plan on using. Providing these to your insurance plan will give you an even better answer. 

3) Ask your medical provider

Ask if they believe your procedure will be covered. They are constantly working with insurance and should have a rough idea of whether certain procedures are covered by insurance or not. However, take what they say with a grain of salt. Providers work with many different insurances and likely aren't entirely familiar with your plan or it's benefits. 

4) Make sure the provider and facility are in-network.

Even if a procedure is generally covered, using an out-of-network provider can lead to denials.

5) Confirm whether pre-approval or step therapy is required.

Some procedures must be authorized in advance. In other cases, you may need to try a more conservative treatment first. If those requirements aren’t completed or documented, coverage can be delayed or denied.

Lastly, remember that "covered" does not mean "paid for". You will likely have to pay a small fee (copay or coinsurance) to receive care. 

A few phone calls upfront can prevent a lot of frustration later. And if you want a second set of eyes on it, I’m always happy to help.