The cost of being sick or injured doesn’t necessarily end with the hospital’s bill. Additional expenses that are not covered by most medical plans can quickly add up. Health insurance was developed specifically for financial protection against loss due to sickness or bodily injury and the unexpected out-of-pocket expenses that can blindside even the most careful planner.
American National offers health insurance plans that cover a wide range of necessities, such as supplemental health plans that offer specified coverage. Some are indemnity policies that pay cash benefits for covered incidents and can work in conjunction with your personal medical insurance plan.
COVERAGE FOR TELEMEDICINE MEDICAL SERVICES AND TELEHEALTH SERVICES. (a) A health benefit plan may not exclude from coverage a covered health care service or procedure delivered by a preferred or contracted health professional to a covered patient as a telemedicine medical service or a telehealth service solely because the covered health care service or procedure is not provided through an in-person consultation.
(b) A health benefit plan may require a deductible, a copayment, or coinsurance for a covered health care service or procedure delivered by a preferred or contracted health professional to a covered patient as a telemedicine medical service or a telehealth service. The amount of the deductible, copayment, or coinsurance may not exceed the amount of the deductible, copayment, or coinsurance required for the covered health care service or procedure provided through an in-person consultation.
(c) Notwithstanding Subsection (a), a health benefit plan is not required to provide coverage for a telemedicine medical service or a telehealth service provided by only synchronous or asynchronous audio interaction, including:
an audio-only telephone consultation;
a text-only e-mail message; or
a facsimile transmission.
How can I find a doctor that is in my PPO network?
Your ID card gives the PPO's phone number, mailing address, and internet address, if any. They will have the most current list of providers in your area that are accepting new patients.
How do I file a claim? What is the address to file a claim?
The address for filing a claim is located on the member's ID card. If you do not have or cannot locate your ID card, simply mail a copy of your bills to the Claim Department, P.O. Box 10546, Springfield, MO 65808-0546. Be sure to write your plan number on your bills.
How do I read your Explanation of Benefits statement?
Please select the type of plan for a description of the EOB.
If you believe you have been a victim of healthcare fraud or abuse, or if you would like to report any suspicious healthcare activity concerning your plan, please contact our Special Investigations Unit at 800-899-6520.
Special Investigations Unit, 6th Floor
One Moody Plaza
Galveston TX 77550.
How does a PPO plan benefit me?
The providers who participate in a PPO have generally agreed to reduce the fees they charge our members. The fee reductions benefit both of us. We normally pay less to a PPO provider than we pay to a non-PPO provider. So, of course, we build into our PPO plans some financial incentives for our members to use PPO providers ("in-network"), instead of non-PPO providers ("out-of-network"). When our members go to PPO providers, they will generally find that the provider's charge, is less than a non-PPO provider's charge and that we pay a greater percentage of the total charge. The PPO's lower charge plus our greater benefits level for PPO services equals less money out of our members’ pockets.
Note: If a member receives services from a PPO provider, and such services are not eligible for benefits under the PPO plan, then the PPO provider may be free to charge his/her normal fee for such services. The charge may not be subject to the PPO Agreement which we have with the PPO.
How does my plan pay?
The Plan booklet contains a BENEFITS section that describes how any deductible, co-payment or maximum payment would be applied. Your plan booklet also included a Schedule of Benefits or Certificate Schedule that specifies your deductible, co-payment (if applicable) and plan maximums.
I am a provider or resident of Florida and would like to obtain a prior authorization form for a prescription or other medical service.
The state has established a standardized form for the preauthorization of prescription drugs and other medical services. You may download the instructions below and select the form for the appropriate company:
I live in Louisiana and have a PPO plan. Where can I find links to the participating hospitals in-network physicians?
There is only one PPO currently utilized in Louisiana. Please follow the link below to your respective PPO provider list.
HEALTH CARE SERVICES MAY BE PROVIDED TO YOU AT A NETWORK HEALTH CARE FACILITY BY FACILITY-BASED PHYSICIANS WHO ARE NOT IN YOUR HEALTH PLAN. YOU MAY BE RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE OUT-OF-NETWORK SERVICES, IN ADDITION TO APPLICABLE AMOUNTS DUE FOR CO-PAYMENTS, COINSURANCE, DEDUCTIBLES, AND NON-COVERED SERVICES.
SPECIFIC INFORMATION ABOUT IN-NETWORK AND OUT-OF- NETWORK FACILITY-BASED PHYSICIANS CAN BE FOUND AT THE WEBSITE ADDRESS OF YOUR HEALTH PLAN OR BY CALLING THE CUSTOMER SERVICE TELEPHONE NUMBER OF YOUR HEALTH PLAN.
I live in Mississippi and would like to learn more about the PPO process. Do I need referrals to see a doctor? What happens if I can’t find a PPO doctor?
Our company has established a product that utilizes a Preferred Provider Organization (PPO) network to offer professional health care as needed. The principle of a PPO is to bring savings to you, the consumer, by providing a higher level of coverage (coinsurance) and reduced premiums, while directing business to providers. This benefits physicians and facilities in the PPO because they get potential patients, rather than needing to advertise to draw in business. For the insurance company, our expenses reduce, allowing us to reduce the member premiums.
Ultimately, the coverage is yours to utilize as you please. You are in the “driver’s seat”, steering the course of your medical care. You have the freedom to choose any medical provider in the network that is accepting new patients. You also have the ability to change medical providers to fit your need at any time. You only need go to the PPO’s website address on your ID card or call them for a list of providers. Their toll-free number is also on your ID card.
When it is an Emergency or a PPO Provider is not Available
We know that sometimes no matter how hard you try, a PPO provider is not available and you will need to see an out-of-network, or nonpreferred provider. In these situations, you are still covered. In the following situations, we allow services as if performed by a PPO provider:
(1) due to the emergency nature of the care;
(2) when no preferred provider is reasonably available within the designated service area for which the policy was issued; and when a nonpreferred provider's services were preauthorized based upon the unavailability of a preferred provider;
(3) when the insured utilizes an in-network facility and the facility-related providers are not in-network (this applies to pathologist, radiologist, anesthesiologist, physical therapist, occupational therapist, respiratory therapist, or other physical medicine provider); or
(4) when the insured has no choice in an assistant surgeon, if the surgeon is an in-network PPO provider.
In these situations, our company will pay a claim by a nonpreferred provider at the usual or customary charge for the service at the higher, preferred benefit coinsurance level, less any patient responsibility. Furthermore, when the insured provides documentation of payments made above and beyond the allowed amount, we will apply this amount to the insured’s deductible and annual out-of-pocket maximum applicable to in-network services.
Our company utilizes Fair Health, a nationally recognized vendor, to determine usual, reasonable, or customary charges. Fair Health employs generally accepted industry standards and practices for determining the customary billed charge for a service that fairly and accurately reflects market rates, including geographic differences in costs. Allowances are based on sufficient claim data to constitute a representative and statistically valid sample. Such data is updated twice per year and is no more than three years old. The methodology is consistent with nationally recognized and generally accepted bundling edits and logic.
Referrals, Discharge Planning and Continuity of Care
Your plan is not an HMO, where either a designated Primary Care Provider (PCP) carefully coordinates care, or you have no coverage. You have the freedom to use whichever provider you choose. Likewise, you have more responsibility for your care. Your plan does not require referrals from one provider to another; you are free to choose from any of the providers in your PPO network.
Your PPO (“preferred”) provider has a responsibility to work with you through necessary changes.
• Referrals to another provider, such as specialists, for second opinions, etc.
• Discharging from a hospital, setting up rehabilitation services or home health care.
• It may be that a PPO provider will separate from a PPO network, whether because of retirement, relocation, or other reason.
When that happens, the provider has a contractual responsibility to help you transition to your next provider. In addition to these protections, we are only a toll-free number away.
I live in Texas and have a health plan with a utilization review requirement. Where can I locate the federal external review forms?
I live in Texas. Where can I locate the Texas Prior Authorization Request Form for Prescription Drug Benefits?
You can download the form by clicking here. Please note that the patient must be eligible and your plan must have prescription coverage to qualify for benefits.
I reside in California and would like to get more information about mental health coverage, utilization review and the appeal process. Where can I locate information specific to California?
The appeal process relating to questions of utilization review, experimental/investigational, medical necessity, external review and language assistance are addressed in this document.
I reside in Indiana. What are my precertification requirements?
You can call Customer Service (see the number on your ID card) or check your plan booklet to determine whether your plan has a precertification requirement. If it does, the following applies:
1. All Inpatient Hospitalizations and procedures done at an Outpatient Surgery Facility must be pre-certified.
2. To comply with the pre-certification requirements, the Covered Person must:
a. Contact the professional review organization at the telephone number contained in the Insured’s Certificate (1-866-344-6746) as soon as possible before the expense is to be incurred; and
b. Comply with the instructions of the professional review organization and submit any information or documents they require; and
c. Notify all Doctors, Hospitals and other providers that this insurance contains pre-certification requirements and ask them to fully cooperate with the professional review organization.
3. If the Covered Person complies with the pre-certification requirements, and the expenses are pre-certified, the Company will pay Eligible Expenses subject to all terms, conditions, provisions and exclusions described in the plan booklet.
4. If the Covered Person does not comply with the pre-certification requirements, or if the expenses are not pre-certified, a penalty may apply, which may consist of a reduction of Eligible Expenses or a reduction of benefit. See your plan booklet for more detail.
5. Emergency pre-certification: In the event of an emergency Hospital admission, pre- certification must be made within 48 hours after the admission, or as soon as is reasonably possible.
6. Concurrent Review – For Inpatient stays of any kind, the professional review organization will pre-certify a limited number of days of confinement. Additional days of Inpatient confinement may later be pre-certified if a Covered Person receives prior approval.
7. Pre-certification Does Not Guarantee Benefits – The fact that expenses are pre-certified does not guarantee either payment of benefits or the amount of benefits. Eligibility for and payment of benefits are subject to all the terms, conditions, provisions and exclusions herein.
I reside in Massachusetts and would like to get an estimate of my cost on a proposed medical service.
Providing your estimated cost requires some detailed information. The more information you can provide up front will allow us to provide a quicker response. At a minimum we will require the provider contact's name and phone number. If possible, please provide the following information as well:
CPT (procedural) code or detailed description of service(s) being rendered;
Amount being billed for each service;
Approximately when the service will be rendered; and
I reside in Tennessee and would like to get more information about the appeal process and external review. Where can I locate the procedures for my state?
The appeal process relating to questions of utilization review, experimental/investigational, medical necessity and external review are addressed in the procedures attached. Please select the link that applies to the carrier:
I reside in Texas. Is there a resource that describes my PPO network? Is there an Access Plan that applies to my coverage?
Pursuant to Title 28 Texas Administrative Code § 3.3705(b), the PPO network disclosure can be accessed by selecting the link corresponding with the company with whom you are insured. Next to the company name is a second link that will provide you the company’s Access Plan, as required by the state of Texas.
If I am a provider in New Jersey and would like to appeal the payment amount on a claim, does the state specify a form?
The appeal process relating to questions of utilization review, experimental/investigational and medical necessity are addressed in the plan booklet. For other payment appeals the state of New Jersey enacted the Provider Independent Claims Payment Arbitration (PICPA) process, requiring use of a carrier-specific Health Care Provider Application to Appeal a Claim Determination form (DOBICAPPCAR 10/10). Company-specific Provider Independent Claim Payment Arbitration (PICPA) forms are below. Please select the link that applies to the carrier:
Your doctor’s office should be able to tell you whether they are a participating provider. In addition, you may look at your ID card to find the name of your PPO, and then view their website to determine if your doctor is in the network. If your PPO does not have a website, a phone number will be on your ID card. Call that number to find out if your doctor is in the network.
What is a Preferred Provider Organization (PPO) plan?
A Preferred Provider Organization (PPO) is a group of hospitals, physicians, and other health care providers who have signed an agreement to treat members. Their charge is based on a negotiated fee schedule. The negotiated fee schedule is part of the formal agreement. Routinely, the negotiated fees are significantly less than the fees patients otherwise pay. The providers who are involved in such agreements are referred to as "participating providers".
Many of our health plans use financial incentives for our members to use the participating providers of a specific PPO. We refer to such plans as "PPO Plans". If a member has a PPO plan and does not choose to use a participating provider, we will pay a lesser benefit, as specified in the PPO plan.
What is covered under the office visit co-pay?
Not every plan has the Office Visit Co-Payment option. If this is referenced in your Schedule of Benefits or Certificate Schedule, please refer to the section entitled "Doctor's Office Visit Co-payment" and/or "How the Preferred Provider Plan Works." They identify the services that are eligible under this provision, if covered by your plan.
What is the effective date of my coverage?
The Schedule of Benefits or Certificate Schedule contains your effective date of coverage.
What is the name of my PPO?
If your plan includes a Preferred Provider Organization (PPO), the name of the PPO will be located on your ID card.
What mental illness/substance used benefits am I provided in the state of Maryland?
If your plan meets the definition of a “Health Benefit Plan” as defined by Code of Maryland §15–1301 or §15–1401 (click here for definitions), the plan will provide at least the following benefits for the diagnosis and treatment of a mental illness, emotional disorder, drug use disorder, or alcohol use disorder:
1) inpatient benefits for services provided in a licensed or certified facility, including hospital inpatient and residential treatment center benefits;
2) partial hospitalization benefits; and
3) outpatient and intensive outpatient benefits, including all office visits, diagnostic evaluation, opioid treatment services, medication evaluation and management, and psychological and neuropsychological testing for diagnostic purposes.
The benefits under this section are required only for expenses arising from the treatment of mental illnesses, emotional disorders, drug misuse, or alcohol misuse if, in the professional judgment of health care providers:
1) the mental illness, emotional disorder, drug misuse, or alcohol misuse is treatable; and
2) the treatment is medically necessary.
The benefits required under this section:
1) shall be provided as one set of benefits covering mental illnesses, emotional disorders, drug misuse, and alcohol misuse;
2) shall comply with 45 C.F.R. § 146.136(a) through (d) and 29 C.F.R. § 2590.712(a) through (d);
3) may be delivered under a managed care system; and
4) for partial hospitalization, may not be less than 60 days.
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits.
MHPAEA originally applied to group health plans and group health insurance coverage and was amended by the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the “Affordable Care Act”) to also apply to individual health insurance coverage.
Many plans do not have a precertification requirement. You have two very good sources: the Schedule of Benefits or Certificate Schedule and your identification (ID) card. If your plan has a precertification requirement, your ID card will give you a toll-free number to call.
If you have a precertification requirement, but fail to precertify, a penalty may be applied. Again, check your Schedule of Benefits or Certificate Schedule for the potential penalty.