Summary of Understanding the Language of Health Insurance

Part 1: The Basic Tools, Chapter 3: Developing a Systematic Approach to Dealing with Health Insurance Page 3

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Sample Information File

Question	Answer
What is the name, mailing address, and phone number of your insurer?
What is your insurance company identification number?
How much is the individual yearly deductible (and the family deductible, if you have family coverage)?
What are the yearly and lifetime benefit maximums?
What kinds of preventive care (routine physical exams, vaccinations, screening tests) are covered?
What special rules exist for reimbursement for the treatment of mental and emotional illnesses?
What services or treatments require pre-authorization? What are the steps for obtaining pie-authorization?
If there is a network of medical providers, where can the up-to-date list of those providers be found?
Does your policy offer reimbursement for services performed by non-network providers?
How much is the co-payment or co-insurance amount (the amount of each bill that you have to pay once the yearly deductible is met)?
How much is the yearly copayment maximum (the total amount your medical bills need to reach before the insurer will pay bills for covered expenses at the 100% rate)?
What percentile is used in the determination of the UCR in terms of major medical claims?
What secondary insurance benefits are offered under the policy, and to whom in the family do those benefits apply?
What are the rules that relate to using the predeter mination of benefits process? (See Step Two)
If you have children, and you have more than one insur ance policy with family coverage, which policy is primary for the children?
What are the steps involved in appealing a claim that has been denied?

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