Some insurance policies require pre-authorization for services. Contact your insurance carrier for verification of benefits and/or if pre-certification of services is required.
It is the patient/parent’s responsibility to confirm that specialty providers are in network with their insurance, as well as to request a prior authorization/referral be processed by the PCP if their insurance plan requires this. Most HMO plans carry this requirement.
Prep for the call
Call the member number on your insurance card and tell them that you “need to verify outpatient/specialist health benefits” or “see if a provider is in-network."
Make sure you have the following information at hand for the call:
- Name of patient
- Name of PCP
- Name of policyholder
- Subscriber number
- Group number
- Specialty and name of the desired provider and their location
- Phone number called:
- Person you talked to:
- Date and time of call:
- Call reference number (if available):
Essential information to collect:
1. Is (doctor/therapist name) currently a network provider for my plan
2. If not, who is considered in-network? What are my out-of-network benefits?
3. Is pre-certification necessary? (Note: Vocabulary changes across carriers. This may also be called an “authorization.”)
Helpful financial information for you (if needed):
1. If (Private Insurance) Do I have a deductible for these services? If yes, how much is it, and how much has been met so far?
2. In what month does your policy year begin?
3. What is my co-payment for each visit, or what is the percentage of coverage?
4. What are the restrictions or limitations to my coverage? (For example dollar amount per year or number of visits per year)
By talking to your insurance company directly, you reduce the chance of having unexpected expenses and can help the referral process from our office.
*TIP: If you are certain your plan does not require pre-certification for a service or visit, you can look up in-network providers on your insurance carrier’s website or from an insurance member portal.