Uncedo xa kungekho nabanikezeli okanye abaqeqeshiweyo kwi-network
Ikhefu le-intanethi yechungechunge isixhobo se-inshorensi yezempilo isebenzisa ukuhlawulela izikhewu kwinethiwekhi yabo yabanikezeli bezempilo. Xa i-inshurensi yakho yempilo inika i-exceptional gap yekhethelo, eyaziwa njengekhefu lekhefu le-klinikhi, ikuvumela ukuba ufumane unyango lwezempilo kwi - provider -network- ntlawulo ngelixa uhlawula iifizi zokuhlawula iindleko eziphantsi.
Yiyiphi i-Network Gap Exception
Ngaphandle kwekhefu lokungabikho kwenethiwekhi, xa ubona umnikezeli wangaphandle-wenethiwekhi, uya kuhlawula ngaphezu kokuba ubuya kuhlawula ukuba usebenzisa i-in-network provider. Ukuba unayo i- HMO okanye i- EPO , isicwangciso sakho sezempilo asiyi kuhlawula i-dime enye yeendleko zokunyamekela kwakho ngaphandle kwenethiwekhi ngaphandle kokuba ufumane ikhefu le-network. Ukuba unesicwangciso se- PPO okanye i-POS, isicwangciso sakho sezempilo siya kukunceda uhlawule unyameko ophuma kuyo. Nangona kunjalo, i- deductible yakho, i- coinsurance kunye ne-copayments iya kuba kakhulu xa usebenzisa umnikezeli wangaphandle ngaphandle kokuba usebenzisa i-network-provider.
Ukucela ikhefu le-intanethi kwi-insurer yakho yezempilo ngokusemthethweni ucela umkhushurensi ukugubungela unonophelo owufumana kumniki -ntanethi ngaphandle kwenani lomnatha . Ukuba i-inshurensi yakho inika i-gap ye-gap yekhefu, uya kuhlawula i-intanethi ephantsi, i-copay, okanye i-coinsurance yaloo nkonzo.
Kutheni i-Network Gap Exception ingaNceda
Okokuqala, qaphela ukuba isicwangciso sakho sezempilo asiyi kukulangazelela ukunika ithuba lokungena kwi-network. Yona msebenzi owongezelelekileyo kubo, kwaye unokuphela ngokuba kubiza nabo. Nangona kunjalo, ukuba isicwangciso sezempilo asinakho umboneleli we-intanethi kwindawo yakho okanye ukuba lowo mboneleli akakwazi ukubonelela ngenkonzo yonyango oluyidingayo, akunakulungele ukuhlawula imali ephezulu ngenxa yokuba Isicwangciso sezempilo asinalo inethiwekhi yomncedisi owaneleyo.
Ngako ke, i-insurers inokunika ithuba lokungena kwi-network ukuvumela ukuba ufumane unonophelo olufunayo kumniki-ngaphandle wenethiwekhi ngaphandle kokuhlawula ngaphezu kokuba kufuneka uhlawule.
Izizathu Unokufumana Ngaphandle kweNethiwekhi yeGap
Akunakwenzeka ukuba unikezwe ngaphandle kwekhefu lenethiwekhi ngaphandle kokuba oku kulandelayo kuyinyaniso:
- Ukunyamekela owucelayo kuyinzuzo ebonelelwe kwaye kuyimfuneko yempilo .
- Akukho mnikezeli-inethiwekhi onokukwazi ukubonelela ngenkonzo oyifunayo kwimida efanelekileyo. Isicwangciso ngasinye sezempilo sichaza ngokwalo ukuba umgama ofanelekileyo. Kwezinye izicwangciso zempilo, mhlawumbi i-50 miles. Kweminye, ingaba ngumgama omkhulu okanye omncinci.
Ukuba imeko yakho ihambelana neemfuno ezingentla kwaye ufumene umboneleli-ngaphandle-wenethiwekhi ohlangabezana nazo zonke iimfuno zakho, ungathumela isicelo kwiinkampani zomshuwalense wezempilo kwi-exceptional gap. Kwezinye iimeko, umnikezeli-ngaphandle wenethiwekhi unokukulungele ukwenza oku kuwe; kwezinye iimeko, kuya kufuneka uyenze ngokwakho.
Kufuneka ucele i-gap yekhefu ngaphambi kokufumana unonophelo . Ukuba ulinda de emva kokuba ufumene unyameko, isicwangciso sakho sezempilo siza kubamba ibango nje-ngaphandle kwenethiwekhi kwaye uya kuhlawula ngaphezulu.
I-Excel Gap Exception kuphela ivala inkonzo eyodwa ecacileyo
Uluhlu lwentengo yenethiwekhi alukuniki i-blanche ye-card ukuze ubone umboneleli-ngaphandle wenethiwekhi nayiphi na inkonzo enqwenelayo, nangaliphi na ixesha ofuna.
Kunoko, xa umgcini-inshurensi unikela ikhefu lomnxeba, inxalenye ibonisa kuphela inkonzo ethile enikezelwa ngumniki-ntanethi othile ngaphandle kwexesha elide.
Yintoni oya kuyidinga kwisicelo sakho sokungafunwa
Ingcaciso oya kuyidinga xa usenza isicelo sokukhetha i-gap yekhefu kubandakanya:
- Ikhowudi ye- CPT okanye ye-HCPCS ichaza inkonzo yonyango okanye inkqubo oyifunayo.
- Ikhodi ye-ICD-10 ichaza ukuxilongwa kwakho.
- Ulwazi loqhagamshelwano lomnikeli-ngaphandle-wenethiwekhi.
- Uhlobo lwexesha ngexesha ulindele ukufumana inkonzo eceliwe. Umzekelo, ukususela ngoFebhuwari 1, 2018, ukuya kuJulayi 31, 2018.
- Amagama abaniki-nkonzo bee-intanethi ezifanayo kwindawo yakho yeendawo kunye neenkcazo zeso sizathu sokuba umniki-ntanethi othile akakwazi ukwenza inkonzo.
Ukuqinisekisa ukuba ikhefu loxhumo lwenethiwekhi luquka iinkonzo ozifunayo, fumana iikhowudi ze-CPT, iikhowudi ze-HCPCS, kunye neekhowudi ze-ICD-10 ezivela kumnikezeli wakho ongaphandle. Ukuba oku kunzima ngenxa yokuba awuzange ube ne-aphoyintimenti kunye nalo mnikezeli okwangoku, ugqirha owakuthethayo unokukwazi ukukunika iikhowudi zezokwelapha ezifunekayo.
Ukuchaza isizathu sokuba uMboneleli wakho onxibelelwano lweNethwekhi angayi KukuCima
Ukuba kukho nabanikezeli bee-intanethi bobugcisa obufanayo njengomniki-ntanethi ongaphandle komnxeba ocela ukungeniswa kwekhefu lenethiwekhi, kuya kufuneka uchaze inkampani yakho yinshorensi yezempilo ukuba kutheni ungenakusebenzisa i-in-network umniki.
Nasi umzekelo. Masithi udinga ukuhlinzwa kwendlebe kwaye ucela ikhefu lomnatha wenethiwekhi ukukhupha i-otolaryngologist ye-otolaryngologist ekwenzeni utyando. Nangona kunjalo, kukho i-otolaryngologist ngaphakathi kwendawo yakho. I-otolaryngologist ye-intanethi isele ikhulile, inokutshatyalaliswa kwesandla, ngoko ke ayisayi kwenza utyando. Ukuba awusebenzi kakuhle ekuchazeni isicwangciso sakho sezempilo sokuba kutheni inkonzo ye-otolaryngologist ingenakho ukubonelela ngenkonzo oyifunayo, isicelo sakho sinokuphikiswa.
Yintoni ongayenza Ukuba isicelo sakho sitshitshisiwe
Musa ukuyeka nangona isicelo sakho siphihliwe. Shayela inkampani yakho yenkampani yomshuwalense ukuba ubone ukuba kutheni. Ngamanye amaxesha, izicelo ziphikisiwe ngenxa yezizathu ezilula ezifana:
- I-inshurensi ayikwazanga ukudibanisa ne-office-provider-network.
- Umshuwalense ucinga ukuba kukho ababoneleli benethiwekhi abanakho ukubonelela ngenkonzo efanayo.
- I-insurer ayinayo idilesi yakho kwaye icinga ukuba uhlala kufuphi nabanikezeli benethiwekhi kunoko.
Zonke ezi mpazamo zinokucinywa. Emva kokuba uqonde ukuba kutheni isicelo sichithwe, unokubhenela eso sigqibo okanye ungenise isicelo esitsha senu esibandakanya ulwazi olongezelelweyo ukuqinisa isicelo sakho.