Health insurance is a contract between you and your health insurer to cover your medical expenses. Your health insurance company helps pay for some or all of your medical care, depending on the type of insurance plan you have. If you have questions about your coverage, we also encourage you to check with your insurance company.
Prior authorization and non-covered benefits
Your doctor will decide which procedures, tests, and other consultations you may need. However, many health plans require referrals, prior authorization, and/or sometimes predetermination of medical necessity prior to care being provided to cover your service(s).
Examples of services that may require authorization include surgeries, planned admissions, therapy, and advanced imaging procedures such as CT, MRI, and PET scans. Beyond prior authorization, some services may not be a covered benefit under your plan all together. These services are considered an “excluded benefit” under your plan.
The UW Health Financial Clearance team will work with your insurance company to obtain your necessary prior authorization(s). How early we start your authorization will vary depending on the service you are receiving. However, you can assume we will start your authorization 3-6 weeks before your date of service. Be aware that investigating coverage requirements, limits, and obtaining authorization from your insurance carrier, especially for complex or investigational surgeries, can take up to six weeks. We will only notify you if there is an issue with your approval. If you are questioning if your insurance has authorized your upcoming service, reach out to your health insurance’s member services department.
What you need to know
You are responsible for knowing your:
Health insurance network (i.e., what locations are in-network versus out-of-network)
Managed care plans such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) may deny or reduce benefits if care is obtained outside of the established “in-network” locations
To go to an “out-of-network” location and have your health insurance pay, you may need a referral or gap exemption from your health insurance.
Check with your health insurance member services department to find out if UW Health is considered an in-network facility for the services you are seeking.
Authorization and precertification requirements
Insurance plans that require prior authorization or pre-certification may not pay for services if it is not authorized prior to the date of service. In such cases, you may be financially responsible for the provided services.
If there are any issues with your insurance authorization, the UW Health Financial Clearance Department will work with your provider to determine medical urgency, and we will then contact you. At that time, you may be given options on proceeding with your service, pre-paying, or rescheduling.
Noncovered benefits under your health plan.
Your health insurance likely has certain services that it does not cover (examples may include acupuncture, fertility care, etc.). You are responsible for knowing if your insurance does not cover certain types of services.
You are financially responsible for services not covered under your health insurance benefits.
UW Health highly recommends that you contact your insurance company to determine your specific benefits for the UW Health location at which you plan to be seen.
