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This is the maximum amount the plan will pay for a covered health care service. May also be called "eligible expense", "payment allowance", or "negotiated rate" depending on your insurance company.
A request to your health insurer or plan to review a decision that denies a benefit or payment (either in whole or in part).
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You generally pay coinsurance plus any deductibles you owe.
A fixed amount (for example, $35) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Yearly amount set as the most each individual or family can be required to pay in cost sharing during the plan year for covered services. An amount you could owe for covered health care services before your plan begins to pay. An overall deductible applies to all covered items and services. A plan with an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles. (For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible.)
Health care services that your plan doesn’t pay for or cover. Patients and their families are responsible for the full cost of the services themselves if they choose to still receive care that is considered an exclusion from their plan.
An expression of dissatisfaction or a complaint that you communicate to your health insurer or plan. A Grievance occurs after an appeal has been completed and also denied.
Exchange plans may require a referral, please have your PCP or Referring Surgeon to contact the exchange plan to refer you to our department. We do not participate in many plans. Please check if we are in your network.
We verify your insurance, network and benefit coverage to come to our Colorectal and Fetal department only. Once that is completed, your care team is notified that services can be scheduled for your child. This is typically a fairly quick process that takes only a few days to accomplish.
Insurance companies sometimes allow a few days in the hospital to start. Once the number of days the insurance company said your child can be in the hospital has passed we will get extensions, day by day, until your child is ready to go back home.
If you insurance denied the surgery, we will file an appeal to try to get the insurance company to reconsider. Sometimes the insurance company wants to speak to our surgeon directly, we will submit documents again if there is no exclusion. If the insurance company denies the need for surgery again, your family can file a grievance with the insurance company.
Use our online contact form. Or, for more information about the Division of Pediatric General and Thoracic Surgery of Cincinnati, call 513-636-4371.