Understanding Insurance Benefits

We know that understanding insurance benefits or obtaining the necessary referrals or authorizations to begin or continue treatment can be confusing.

If you have coverage with your insurance company for fertility services, it is important to have a good handle on the pre-treatment processes that are required by your insurance plan. In order to assist you with this, we have provided you with some tools for your insurance investigations.

Our office will also be contacting your insurance company to better determine your plan requirements and benefits available. We will investigate your benefits soon after your initial consultation so that you know what is covered before any testing or treatment is initiated. Please be aware that we can only contact your insurance company; we do not administer your benefits and are not able to change your insurance company’s determinations. Most insurance plans do start new deductibles on January 1 of the year. However, your plan may have a different date; please check with your insurance company for specifics about your policy. It is the responsibility of the insured to know the benefits of their particular policy.

Please understand that the patient is ultimately responsible for all non-coverage or under paid services. The Fertility and Reproductive Medicine Center is not responsible for any incorrect information that the insurance company may have provided or any omitted information regarding limited/non-benefits or waiting periods. Be aware that any outstanding balances and/or co-pays must be paid at the time of each visit.

Billing codes are determined based on the documentation of the service provided and the presenting diagnosis. We are happy to review any questions of accuracy, but due to federal regulations, we cannot misrepresent the service provided or presenting diagnosis.

Some insurance companies will only verify that a procedure code is ‘billable.’ This is simply a determination that we can bill the service and the procedure code is valid. It is not a guarantee of coverage or payable service. We highly recommend that you check your policy for limitations regarding coverage.

Preauthorization / precertification

Some insurance plans require the patient or the healthcare provider to obtain an approval from the insurance company for certain medical services before agreeing to cover the services.

This approval process is called preauthorization or precertification.

Preauthorization or precertification does not guarantee payment. While an insurance company may preauthorize a service, they have the right to determine later not to cover the service.

Questions to ask your insurance company

  1. Do I have infertility benefits under my current insurance company?
    1. If no, do I have diagnostic testing covered which may cover my initial consultation and diagnostic work-up?
  2. If I were to see a reproductive endocrinologist in a consultation, would I have coverage for an office visit? Do I need a referral from my OB/GYN or primary care physicians, a pre-authorization, or to enroll in an infertility program?
  3. Do I have infertility treatment coverage so that I can have artificial insemination (IUI), in vitro fertilization, intracytoplasmic sperm injections (ICSI) and cryopreservation (freezing of embryos or sperm) or egg donor treatment?
    If yes:

    1. Does my policy require prior authorization for these procedures?
    2. If I have fertility coverage for these procedures, what is my maximum lifetime infertility benefit?
    3. What is my deductible/co-pay/co-insurance for infertility related charges?
    4. Does my policy cover oral or injectable medications? If yes, does my policy require prior authorization?
    5. Do I have a specialty pharmacy where my medication order must go in order to get coverage?
    6. Do all of my medications go here or just the injectable ones?
    7. What is the phone number they must contact to accomplish this? The fax number?

Self-pay packages

The Fertility and Reproductive Medicine Center offers a deeply discounted benefit to our patients in the form of a self-pay package for certain services.

Self-pay packages are offered to patients:

  • Who have elected to seek our services knowing that we are not network providers with their insurance
  • Who have elected, for privacy reasons, not to bill their insurance for services specified in the self-pay package documents
  • Who have no or limited fertility benefits in their policy. We will provide the information given by your insurance company. It is up to you to verify this non-coverage or limitation of coverage before proceeding with this option. Once you have verified this information to be accurate, any funds are received from your insurance company in payment for the services detailed in the package will be refunded to the insurance company in assumption of erroneous payment.