Health Insurance FAQs

If a service is ‘covered’ by your insurance that means it is included in your benefits. Those benefits also determine the portion of out-of-pocket cost associated with the service.

If a service is excluded, it is not included in your benefits. You may choose to pursue that service and pay for it yourself.

• Insurance companies will tell you: “Benefit quotes are not a guarantee of payment. Payment is determined at the time a claim is received.”
• The Emily Program checks coverage for all of our services against your benefits as accurately as possible; however, many client-specific variables will impact your benefits once a claim is sent. These variables include: Diagnosis code, length and frequency of visits, service location, and treating provider.

The total cost of treatment is determined by your benefits at the time services were provided. This includes network status, out-of-pocket payments made year-to-date, insurance pricing for these services, and The Emily Program’s contract with each insurance company. These factors (among many others) affect how a claim is processed and paid by insurance – and with this many variables, it isn’t possible to provide estimated total out-of-pocket costs with accuracy.

Insurance may require additional permissions (authorizations) be obtained by The Emily Program before services can be provided. Authorizations for service generally are obtained by The Emily Program prior to the service being rendered.

• While the authorization must be approved for the service to be covered, an authorization does not guarantee coverage for a service. If you want to know for certain whether a service is covered, you must talk with your insurance provider.
• Insurance payment is determined at the time a claim is received and decisions are based on medical necessity.

“Coordination of Benefits” is an annual requirement for all insurance companies to determine if additional insurance coverage exists. If dual insurance coverage does exist, Coordination of Benefits will determine which plan is primary, and which plan is secondary. If Coordination of Benefits is needed on your plan, all services billed will be denied and you will be responsible for 100% of the amount owed.

• Call your insurer and inform them if you have additional coverage (e.g., a secondary insurance company.)

When dual-insurance coverage exists, one of the plans identifies as primary, i.e., the ‘first in line’ to pay for your healthcare services. The other will identify as secondary. Services are billed to both insurance plans prior to deductible or co-insurance costs being billed to the client. Call your insurance provider to have Coordination of Benefits set up with both plans prior to claims being processed through insurance (see above).

The Emily Program submits claims to insurance based on the service rendered, the amount of time for each service, the medical information required (i.e. diagnosis code), and the contract we have with the insurance company. Claims cannot be adjusted to accommodate your benefits.

• Patient responsibility amounts are determined by your insurance company, not The Emily Program.