Izibango eziPhezulu ezi-10 eziPhezulu ziLahlwa

Ukuqonda izizathu zokuba kutheni amabango ezonyango anqatshelwe ngabagcini bomshuwalense anokuncedisa ukunciphisa inani lokuchasa iofisi yakho yezobugqirha. Indlela yodwa yokuzikhusela kukuba bazi ukuba ziphi.

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Ulwazi lweNgcaciso loMonde

Kubalulekile ukufakela ibango lezonyango ngolwazi oluchanekileyo lokuchonga isiguli. Ngaphandle kwale nkcazelo ebalulekileyo, isicwangciso se-inshorensi yezempilo ayinakukwazi ukubona isigulane ukuba sihlawule okanye sisebenzise ulwazi lwesibango sisetyenziswe kwi-akhawunti ye-inshurensi yezempilo yesigulane.

Ezinye zeempembelelo eziqhelekileyo ezinokubangela ukuba ibango likhanye ngenxa yokungachanekanga kolwazi lokuchonga isigulane:

• Igama lomgcini-sicelo okanye isigulane sichazwa ngokungalunganga
• Umhla wokubhalisa okanye isigulane sokuzalwa kwibango ayifani nomhla wokuzalwa kwenkqubo ye-inshorensi yempilo
• Inombolo yombhalisi ayilahlekanga kwibango okanye ayivumelekanga
• Inombolo yeqela labaxhasi ayikho okanye ayivumelekanga

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Umgca wokuphela

Ukuqinisekisa iintlawulo ze-inshorensi ngaphambi kokuba iinkonzo ezinikezelweyo zingalumkisa iofisi yezobisi xa isigxina se-inshorensi sisebenza okanye siphelile. Oku kuya kukuvumela ukuba ufumane ulwazi oluthe xaxa lwe-inshorensi okanye uphawule isigulane njengomvuzo wokuzihlawula.

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Kudinga ukugunyazwa kwangaphambili okanye ukuqinisekiswa

Iinkonzo ezininzi ezinjengeengxaki ezingekho ngongxamiseko zingadinga ukugunyazwa kwangaphambili. Kuqhelekileyo kubahlawuli abaninzi be-inshorensi bafuna ukugunyazwa kwangaphambili kwezibonelelo ze-radiology ezibizayo ezifana ne-ultrasound, i-CT ne-MRI. Iinkqubo ezithile zokugonywa kunye nezibhengezo zonyango zingadinga ukugunyazwa kwangaphambili.

IiNkonzo ezibonelelwa isigulane esidinga ukugunyazwa kwangaphambi koko kuya kubanjelwa ngumhlawuli we-inshorensi. Iinkonzo aziyi kunqatshelwa ukuba iinkonzo ezinikezelweyo zibhekwa njengengxamiseko yonyango. Umnikeli unokuzama ukufumana ukugunyazwa kwe-retro-authorization kwisithuba seeholide ezingama-24 ukuya kuma-72 emva kokuba iinkonzo zifunyenwe kuxhomekeke kwizikhokelo ze-inshorensi.

Kaninzi

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Iinkonzo ezingabandakanywa okanye ezingekho phantsi

Izibhengezo okanye iinkonzo ezingekho phantsi zibhekiselele kwiinkonzo ezithile ze-ofisi zezokwelapha ezingabandakanywa kwi-inshorensi yempilo ye-inshorensi. Izigulane ziya kufuneka zihlawule iipesenti eziyi-100 kulezi nkonzo.

Esi sisinye isizathu sokuba kubalulekile ukudibanisa i-inshurensi yesigulane ngaphambi kokuba iinkonzo zinikezelwe. Inkonzo yabasebenzi abahluphekileyo ukuyihlawula isigulane kwiimfestile ezingabhalwa ngaphandle kokubenza bazi ukuba bangabangela uxanduva lwezityholo phambi kwenkqubo yabo.

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Isicelo seeNgxelo zezoPhando

Ezinye iinjongo ze-inshorensi zempilo zingacela iirekhodi zonyango xa ibango lifuna amanye amaxwebhu ukuze kugwebe ibango. Iirekhodi zezokwelapha ziquka kodwa zingaphelelanga kwezi zinto zilandelayo:

• Imbali yonyango
• Imibiko yesifo esineemonde
• Iingxelo zokubonisana nodokotela
• Isishwankathelo sokukhutshwa komonde
• Ingxelo ze Radiology
• Iingxelo zomsebenzi

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Ulungelelaniso lweeNzuzo

Ukulungelelaniswa kweenzuzo zokuxhamla kungabandakanya:

• Enye i-inshurensi ibalulekileyo
• I-EOB engekho ( ukulinganisela kwezibonelelo )
• ILungu alizange lihlaziye i-insurer kunye nolunye ulwazi lomshuwalense

Ulungelelaniso lweenzuzo ligama elisetyenziswayo xa isiguli sinesibini okanye ngaphezulu kwiprogram ye-inshorensi yezempilo. Imithetho ethile isebenza ukucacisa ukuba yintoni iplani ye-inshorensi yempilo ehlawula iiprayimari, ezisekondari okanye eziphezulu Kukho izikhokelo ezininzi ukufumana ukuba yintoni umyalelo weofisi yezobugqirha kufuneka ibhawule nganye isicwangciso se-inshurensi yezempilo.

Kaninzi

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IBhili yoLawulo lweMfanelo

Ukuba ibango likhokhiswe njengengozi yomsebenzi wenzalo-mali okanye inxulumene nomsebenzi, abanye abathwali baya kunqaba ukuhlawula kude kube yinto yomshuwalense we-auto okanye umphathi-ntlawulo wenkokhelo yabasebenzi ehlawulwe.

Ngenxa yeenkonzo ezinxulumene neengozi, i-inshorensi yemfanelo yenkampani yesithathu kufuneka ihlale ifakwe njengeyona ndawo:

1. Inqwelo yeenqwelo okanye i-Auto Insurance ngaphandle kwephulo, umgaqo-nkqubo okanye iMed Pay
2. Inkonzo Yomshuwalense Wembuyekezo
3. Intshurensi yomninikhaya
4. I-inshurensi yokungasebenzi
5. I-Intshumo yoNyununu

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Iikhowudi ze-CPT okanye ze-HCPCS ezingavumelekanga

Ukuze iibango zonyango ziqhube kakuhle, kukho iikhowudi eziqhelekileyo ezisetyenziselwa ukuchonga iinkonzo kunye neenkqubo. Le nkqubo yokubhala i-coding ibizwa ngokuba yiNkqubo yeCoding System (HealthCoding System) (i-HCPCS kwaye ivakalise "ukukhethwa kweengxowa.")

Qinisekisa ukuba iinkcukacha zakho zezokwelapha zihlala zifikelele kwiikhowudi ze-HCPCS. Iinguqu kwiikhowudi ze-HCPCS zihlaziywa ngezikhathi ngenxa yamakhowudi amatsha aphuhliswayo kwinkqubo entsha kunye neendlela zangoku zihlaziywa okanye zilahlwa.

Kaninzi

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UkuFakela ngexesha

Qaphela ixesha elifihlayo lokufakela ixesha elide ngexesha lokuhambisa i-inshurensi nganye. Eminye imizekelo yexesha elifihlayo lokuthumela ixesha liquka:

• Ukunakekelwa kweMpilo yeZizwe eziManyeneyo: Imida yokufakela ngexesha elifanelekileyo ichazwe kwisivumelwano somnikeli
• I-Cigna: Ngaphandle kokuba umthetho welizwe okanye omnye usebenziso lusebenza -
  1. Abaniki-nxaxheba benonophelo bempilo banamalungu amathathu (3) (iintsuku ezingama-90) emva komhla wenkonzo.
  2. Abanikezeli bee-out-of-network baneenyanga ezintandathu (6) (iintsuku eziyi-180) emva komhla wenkonzo.
• I-Aetna: Ngaphandle kokuba umthetho welizwe okanye omnye usebenziso lusebenza -
  1. Oogqirha baneentsuku eziyi-90 ukususela ngomhla wokubonelela ukufaka ibango lokuhlawula.
  2. Izibhedlele zinomnye umnyaka ukususela kumhla wenkonzo ukuhambisa ibango lokuhlawula.
• I-TRICARE: Amangalo kufuneka angeniswe kungangonyaka omnye emva komhla wenkonzo.

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Akukho Ukudluliselwa kwiFayile

Ezinye iinkqubo zifuna ukuba isigulane sifumane ukuthunyelwa kwirejista yabo yentsapho ngaphambi kokuba iinkonzo zinikezelwe.