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Understanding your health insuranceLast Updated: July 15, 2005
Investigating your Policy
One way to keep costs down is to EXCLUDE coverage for illnesses that insurers believe are non-life-threatening.
Infertility is seen by many companies to be "elective" and nonlife-threatening.
When examining a claim, insurance companies look at WHAT is procedure is being claimed and the WHY it is being performed. The WHAT and the WHY is the basis of a claim's acceptance or denial.
CPT Codes: ( Physicians Current Procedural Terminology) A listing (and coding) of procedures and services performed by the physician. These codes are systematic standarized and put forth by the American Medical Society.
ICD-9 Codes: These codes give the insurance company the diagnosis from the doctor of your condition.
This gives the insurance company the information about why you are being treated: endometriosis, PID, Blocked Tubes etc.
If insurance companies do not agree with the WHAT (CPT codes) or the WHY (ICD-9) they may deny the claim. Many carriers may cover the cost to diagnose but not to treat.
Knowing how the codes are applied to your insurance may help you not only get something covered but also be sure codes are being properly applied for more efficient payment of the physician or for reimbursement for you.
Get Copies of Your Documents
It is as important to get copies of your own records as it is to see a copy of your insurance contract.
Call you physician's office and get copies of all your labs, notes etc. Then call your (or your spouses) benefits office for contract information. If you are insured individually, call your agent.
The policy comes in two forms, a contract (which is usually not provided to you in a group policy, unless you ask, or a summary plan booklet. The booklet is a brief summary of the benefits.
Read your Documents
Even your booklet is a "contract" written specifically to spell out not only what IS covered but to exclude what is not covered. Disputes over the policy language have traditionally sided with the insured.
Insurance companies are designed to cover the insured in the event they suffer from an "illness" or "injury".
In 1990 The American Fertility Society, now the ASRM (American Society for Reproductive Medicine), defined infertility as a disease. then in 1996, Pacourek v. Inland Steel Co., 64 U.S.L.W. 2550 (N.D. Ill. Feb. 16, 1996) reasoned that including the reproductive system in the regulation's list of body systems which can be impaired for purposes of the ADA would have been superflous had the EEOC rulemakers, and Congress before them, not intended infertility to be a disability covered by the Act. The court also found that a major life activity should be characterized in terms of the quality of life, not merely the frequency of the activity
There are numerous physical problems that accompany infertility as a disease process, endometriosis, polycystic ovarian syndrome etc. Being defined as a "disease or illness" may be a step in the direction of coverage instead of exclusion.
Review carefully this portion of your insurance booklet or contract. Pay careful attention to the terms and definition of the terms and language of the contract.
If a procedure is no specifically listed in the exclusions area of your policy, it would be fair to assume the procedure is covered and this opens the door to an appeal for a denial of coverage.
In the past, insurance carriers that have denied claims for one of the following four reasons:
1. Infertility is not an illness;
2. Treatment of infertility is not medically necessary;
3. Treatment of infertility is experimental.
4. Excluded Treatment
Not Medically Necessary
Traditionally, having a baby is not looked upon as being medically necessary. Most insurers, however, will pay for treatment where an illness or disease contributes to infertility IF treatment is not just for the purpose of getting pregnant.
Because of this, portions of infertility treatments can be broken out and paid for using specific billing codes. Review of the "denied claim" as not medically necessary can often be resubmitted successfully with additional information from the physician.
An Experimental Procedure
In the past IVF seemed to fall under this catagory. Today denying coverage as "experimental" is simply not a valid reason.
You should examine this area very carefully. Most medical procedures have many different components. There may be sub-areas within the procedure that are not excluded and there fore portions of the procedure might be copied.
Look carefully at the language. IVF may not be a covered procedure but when broken down into the billing codes for egg retrieval, embryo transfer, blood work etc, a number of the services might be covered. IVF and embryo transfer might be excluded but with no mention of GIFT (Gamet Intrafallopian Transfer) which could open the door for coverage for this specific procedure.
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