Individual Medical Benefits Health Insurance Frequently Asked Questions

This option uses a PPO Network, which is comprised of a large number of participating hospitals and physicians. The providers in this network have agreed to reduce the amount they charge for services provided to insurance company policyholders. PPO networks may vary depending on the area in which you live.

Who is my PPO vendor?
What is the name of my PPO Network?

This information is printed on your ID card, along with a telephone number for you to contact the Preferred Provider vendor for your policy.

Which physicians and hospitals are members of my PPO Network?
How can I find out if my physician is a member of my PPO Network?

At the time you received your policy, you may have received a directory of physicians and hospitals in your network. If you would like an updated list, please contact your PPO vendor using the telephone number on your ID Card. You may also contact your provider's office and ask if the physician is a member of the PPO network (listed on your ID card). Always verify whether your provider is a member of the PPO network in order to maximize your benefits.

How can I get an updated PPO Network directory?

Please contact your PPO vendor. Always verify whether your provider is a member of the PPO network in order to maximize your benefits.

How do I know if my physician is a member of the PPO Network?

Ask your physician's office if your physician is a member of the PPO network listed on your ID card. You may also call the telephone number listed on your card to contact your PPO vendor.

How do I contact my PPO vendor?

Call the number on your ID Card.

I thought I went to a PPO Network provider. Why doesn't my claim payment reflect this?

If your physician is not listed as a member of your PPO vendor network, benefits will not be paid as a network provider. See your policy for details.

The physician's office charged me for the PPO Network provider discount. What should I do?

Please contact the physician's billing office and explain that they have charged you in error. See your policy for details.

Why are my claims sent to the PPO vendor first?

The PPO vendor determines the discounts that are applied to your bills, and then forwards them to the insurance company.

My PPO Network physician wasn't in the office. I saw the "on call" physician. Will this be paid as a PPO Network claim?

If the physician you saw is a member of your PPO network, we will consider the charges at the PPO rate of payment. If the physician you saw is not a member of your network, we will consider the charges at the non-participating provider rate of payment.

The clinic was a PPO Network provider. Why wasn't the physician paid as a PPO Network provider?

Each physician contracts individually with the PPO network. If the physician you saw is not a member of your network, we will consider the charges at the non-participating provider rate of payment.

I was on vacation and had to see a physician. Will you pay my claim at the PPO Network rate?

**Reasonable and Customary** TOP
Question	Answer
What is reasonable and customary?	Reasonable and customary (R&C) is the dollar amount allowed for a particular service. The reasonable and customary amount for charges is determined using your geographic area.
How can I determine if the charge for a procedure is reasonable and customary?	We are happy to check if a physician's fee for a specific service is within a reasonable and customary range. Please provide us with a CPT procedure code from your physician's office, the physician's tax identification number, and the proposed fee. See your policy package for details.
What do I do if my physician or hospital is billing me for the amount not covered as over the reasonable and customary amount?	There is a specific reasonable and customary amount allowed in your geographic area, and this is the amount allowed by your policy. Anything over the reasonable and customary amount would be your responsibility.

**Preauthorization / Predetermination** **TOP**
Question	Answer
What is preauthorization?	Preauthorization is when you notify us in advance of a surgery or hospital stay, and is required for most policies. The requirements can differ from policy to policy, but the purpose of preauthorization is to determine if a hospitalization or surgery is medically necessary, and how many days of hospitalization are warranted. Your ID card shows the preauthorization telephone number. A full listing of which services require preauthorization can be found in your policy. Please follow the preauthorization procedure in order to maximize your benefits.
What is a predetermination?	A predetermination of benefits is a written request for verification of benefits. We review these requests based on policy provisions, and send an explanation of your potential benefits. You may request a predetermination before your medical procedure, although a predetermination of benefits is generally not necessary.
Does my surgery/hospital stay need preauthorization?	In most cases, preauthorization is a requirement for services listed in your policy. Please review your policy package for details.
How do I get my surgery/hospital stay preauthorized?	Your ID card shows the preauthorization telephone number. A full listing of which services require preauthorization can be found in your policy. Please follow the preauthorization procedure in order to maximize your benefits.
How am I notified whether or not my surgery/hospital stay is preauthorized?	Your preauthorization vendor will send you a telegram that will explain if the procedure and/or hospital stay is approved or denied. If you are being hospitalized, the specific number of days approved will also be provided.

**Submitting Claims** TOP
Question	Answer
How long do I have to submit a bill/claim?	Please submit the claim as soon as you can. The insurance company cannot consider any claim received more than 15 months after the date of service.
How do I get a claim form for my prescriptions?	Usually, the pharmacy will submit prescription claims for you. If not, you can request a claim form. See policy details.
Can I fax in a claim?	You can fax a claim. See your policy for details.
How do I submit a claim if I am also covered by Medicare?	Usually, your physician's office will submit the claim for you. Otherwise, you should submit your claim to Medicare first. Then the claim (along with a copy of your Explanation of Benefits from Medicare) should be submitted to the insurance company. See your policy package for details.
Where do I submit my prescription receipts?	Usually, the pharmacy will submit prescription claims for you. Otherwise, simply complete a Prescription Drug Claim Form, attach your receipt(s) and mail it to the address on your prescription ID card.

**Claim Status Questions** **TOP**
Question	Answer
How long does it take to process a claim?	The amount of time it takes to process a claim depends on the information submitted. In general, you should receive an Explanation of Benefits within 3-4 weeks. If additional information is required to process a claim, we will notify you, and the claim could take longer to process.
What is the status of my claim?	To determine claim status, please contact the insurance company Customer Services Department. See your policy package for details.

**Claim Denials** TOP
Question	Answer
How do I appeal a claim denial?	If you believe your claim has been processed incorrectly, contact the insurance company as detailed in your policy. If you do not agree with the denial of a claim, please send an appeal in writing to the insurance company as detailed in your policy. Please note extenuating details, include any documentation pertaining to the appeal, and keep a copy for your records.
Why was my claim denied?	Please review your Explanation of Benefits. A non-covered charge has a corresponding message explaining why the bill was not covered. If you still have questions, please contact the insurance company as detailed in your policy package.
What is your address to send in an appeal?	See your policy package for details.
Can I fax in an appeal?	Yes, you may fax your appeal. See your policy package for details.
My claim was denied as not medically necessary. What does that mean?	Please review your policy's definition of medical necessity. If you disagree with our determination, send an appeal in writing to the insurance company. See your policy package for more details. Note any extenuating details, include any documentation pertaining to the appeal, and keep a copy for your records.
My physical therapy/chiropractic claim was denied as maintenance care. What does that mean?	Maintenance care means that the care that you are receiving is no longer improving your medical condition.
My maternity claim was denied as a routine pregnancy, but I had a complication. What should I do?	Please review your policy's definition of complication of pregnancy. Under this definition, it lists specific complications of pregnancy that are covered by your contract. Not all complications of pregnancy are covered. If you feel that you had a covered complication of pregnancy as defined in your policy, please send an appeal in writing to the insurance company. See your policy package for details. Note any extenuating details, include any documentation pertaining to the appeal, and keep a copy for your records.

**Contact Information** TOP
Question	Answer

How do I send in a claim for my Health Savings Account (HSA)?	Please send it to the insurance company. See your policy package for details. Be sure to note your policy number on the claim.
I have misplaced my policy and I need to obtain a duplicate. How do I get a copy of my policy?	To receive a duplicate policy, please contact the insurance company's Customer Services Department. See your policy package for details.

**Coverage** TOP
Question	Answer
What conditions and procedures are covered by my policy?	Please review your policy for that information, since it can vary from policy to policy. If you still have questions, you may contact the insurance company. See your policy package for details and be prepared with your policy number.
Am I covered when I go out of the United States?	Unless specifically excluded by your contract, you are covered for the benefits listed in your policy. All policy provisions apply, including medical necessity and reasonable and customary.
Do you cover eyeglasses, contact lenses, or hearing aids?	Generally, Individual Medical policies do not cover these items. Please review your policy for that information. If you still have questions, you may contact the insurance company. See your policy package for details.
What is a pre-existing condition?	Please review your policy for that information, since it can vary from policy to policy. If you still have questions, you may contact the insurance company's Customer Services Department. See your policy package for details.

**Prescriptions** TOP
Question	Answer
How do I submit my prescription claims?	Usually, the pharmacy will submit prescription claims for you. Otherwise, simply complete a Prescription Drug Claim Form, attach your receipt(s) and mail it to the address on your prescription ID card.
How do I get prescription claim forms?	Usually, the pharmacy will submit prescription claims for you. Otherwise, to order claim forms, see details in your policy package.
How do I use my Prescription ID card?	Each time you fill a prescription, present your card at a participating pharmacy. Once you satisfy your annual deductible, you pay the copayment specified on your drug card. After applying any discounts, deductibles, or copayments, the pharmacy will submit your claim electronically. To locate a participating pharmacy, simply see your policy package for details.
My prescription was denied because it was "over the days supplied." What does that mean?	Your policy allows up to a 30-day supply of your medication. If your prescription goes over that amount, it may be denied.
My physician prescribed a brand name drug for me. Can I get it covered instead of the generic?	Yes, a brand name drug can be covered, even if the generic drug is available. However, an additional charge will be applied.
Why aren't my injections covered under the drug card?	Injections are covered under your regular policy provisions. Usually, your physician's office will submit the claim for you. Otherwise, please send your claim to the insurance company. A claim form is not required, although they will need an itemized bill. Please indicate: the patient's name date of birth policy number date of service procedure code diagnostic code provider's tax identification number

**Other Insurance / Medicare** **TOP**
Question	Answer
Can I keep my other insurance and this policy in force at the same time?	Please contact the insurance company's Customer Services Department with your policy number. Details are included in your policy package. Since each policy is different, we will need to look up your specific policy information in order to answer this question.
How do I submit a claim if I am covered by more than one insurance policy?	Please contact the insurance company's Customer Services Department. Since each policy is different, we will need to look up your specific policy information to answer this question.
Who is my primary insurance, Affordable Health or Medicare?	In cases where Medicare is involved, Medicare is your primary insurance.
How do I submit a claim if I am covered by both Medicare and Affordable Health?	Usually, your physician's office will submit the claim for you. Otherwise, you should submit your claim to Medicare first. Then the claim (along with a copy of your Explanation of Benefits from Medicare) should be submitted to the insurance company. See your policy package for details.
I had a car accident. Who should pay first, my car insurance or my health insurance?	Please contact the insurance company's Customer Services Department. Details are included in your policy package. Since each policy is different, we will need to look up your specific policy information to answer this question.
I am self-employed. The state I reside in does not require me to have Worker's Compensation. Does my Affordable Health insurance cover me while I am at work?	Yes, you are covered 24-hours-a-day. However, you may need to send additional verification that you are not covered by a Worker's Compensation policy.

**Benefit Coverage** **TOP**
Question	Answer
I already paid the bill in full. Why was the benefit paid to the provider?	If it was not noted on the bill that it was paid in full, benefits are sent to the provider. The physician should reissue the payment to you.
I paid the bill in full at the time of service, but you have now taken a discount. How do I get the discount refunded to me?	Please forward a copy of your EOB statement from Affordable Health to the provider's office. The provider should apply the discount to your account and return any payment to you.
I lost my claim payment check. What should I do?	In most cases, the insurance company can reissue payment. Contact them with your policy number. Details are in your policy package.
My claim payment check is too old to cash. What should I do?	In most cases, we can reissue payment. Details are included in your policy package.
What do I do if the insurance company has overpaid my claim?	We appreciate being informed of any errors. Please contact the insurance company. Details are included in your policy package.

**Insurance Terms** **TOP**
Question	Answer
What is a copayment?	A copayment is the amount you pay for each prescription drug or PPO physician office visit.
What is a deductible?	A deductible is the amount of covered expense you must incur and pay each calendar year before we will pay for covered medical expenses. This is for each individual, each calendar year. Expenses that are not covered by your policy will not be applied to your deductible.
When does my calendar year deductible start over?	The calendar year begins January 1st and ends December 31st each year.
What is coinsurance?	Coinsurance (also known as Rate of Payment) is the percentage of covered expense you are responsible for after you have met your deductible. For example, if your coinsurance is 20% up to $5000, you pay 20% of the expenses and the insurance company pays 80%, up to $5,000. Once you reach $5,000, the insurance company pays 100% of your covered charges, up to the policy maximum.
What is individual out-of-pocket expense?	Individual out-of-pocket expense is your deductible and coinsurance added together. In other words, it is the maximum you will have to pay -- per person, per calendar year ' in deductible and coinsurance.
What is family out-of-pocket expense?	Family out-of-pocket expense is your deductible and coinsurance added together, for your whole family. In other words, it is the maximum you will have to pay -- per person, per calendar year ' in deductible and coinsurance, no matter how many members of your family need insurance benefits.
What is an HSA?	A Health Savings Account is an option that is available on some of the policies that the insurance company sells. For specific information on HSAs, please contact your Cheap Health insurance agent.

**Special Exception Riders** **TOP**
Question	Answer
What is a special exception rider? How do I know if I have one on my policy?	A special exception rider excludes benefits for a specific medical condition for a family member. Not all policies are issued with a special exception rider. If a rider was issued, you would have been notified during the Underwriting process. The rider would be sent with your policy.
There is a special exception rider on my policy. How do I have it removed?	It may be possible to remove a special exception rider from your policy. You must have been insured with the insurance company, and symptom and treatment free for this condition, for two years. If you meet these guidelines, please complete a Supplemental Application and send it to the insurance comany. (To receive a supplemental application, please see information enclosed in your policy package.) In some cases, special exception riders are permanent, and cannot be removed. If this is the case, it will be written on the top of the rider.

**Miscellaneous** **TOP**
Question	Answer
How do I read my Explanation of Benefits (EOB) statement?	The rows are read from top to bottom. Each separate bill submitted to Cheap is on its own line, with corresponding payment details. EOB messages give additional information about how your expenses were considered, if applicable. The last column of each row shows the amount paid for each bill, and the payment box in the lower right corner shows you where the payment was sent.
How do I request copies of past Explanations of Benefits?	Since your EOB copy is your file copy, you should keep it for tax purposes. We are unable to routinely request duplicate copies of EOB statements. If you have questions about how specific charges were considered, please contact the insurance company. Details are enclosed in your policy package.
What information do you need to pay my accident bills?	The date, time and place the accident occurred The circumstances of the accident Others liable for the expenses (for instance, automobile insurance or another third party) Please contact the insurance company with this information.

I found a billing error made by the hospital. What should I do?	If the insurance company has overpaid on a claim because of a billing error made by the hospital, please have the hospital send a corrected claim to our office. In some cases, you may be eligible for reimbursement up to 50% of our savings, up to a maximum of $500. To collect this reimbursement, please have the hospital notify the insurance company that you found the error on the bill. Details are included in your policy package.

TOP

	Save premiums, shelter taxes, and build tax-favored savings*
	Learn more

Get an instant quote and compare plans side by side.
Enter your ZIP Code to get started: