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What is Covered Under a Group Health Insurance Plan in Virginia?

A group plan will only cover the expenses outlined in the policy, certificate, or EOC. A number of factors are considered in determining if a service is covered, and the extent of the available coverage. The following factors should be considered before you submit a claim:

• Is the service covered under the terms of the policy?
  The certificate or EOC will describe the covered services and will list exclusions and limitations.
• Is the service medically necessary?
  Routine services or elective procedures that are not medically necessary will generally not be covered.
• What does the company consider to be an "allowable charge" or a "usual, customary or reasonable (UCR) charge" for the service?
  Many policies and plans establish allowable charges for services and procedures. The charges may be representative of fees charged by similarly situated providers rendering the same services in a given locality, region, or area, (often referred to as "usual, customary and reasonable"), or they may be based on other criteria established by the company. If your plan bases payments on a UCR schedule, or a schedule of allowable charges, you may be responsible for any difference between the UCR or allowable charge and the provider's actual charge. However, in some cases, providers agree to accept the UCR or allowable charge, which means the patient will not be responsible for the difference.
• Is the condition considered a pre-existing condition?
  A group health plan may deny benefits for a pre-existing condition, but there are laws in Virginia that specifically define a "pre-existing condition" and limit how long benefits may be withheld because of a pre-existing condition. Also, certain conditions may not be considered pre-existing.
• Did the patient follow any pre-certification or pre-admission requirements prior to obtaining services?
  Many insurers require pre-admission or pre-certification authorization prior to being admitted for non-emergency services, or receiving certain care. You may be held financially responsible for the cost of the care if you fail to obtain the pre-certification or pre-admission authorization.