INSURANCE AND BILLING ISSUES
Insurance coverage and reimbursement for the testing and treatment of infertility is complex. Once you have become a patient with us our medical billing and insurance specialists will be happy to assist you by completing an in depth insurance benefit determination. They are available to answer any insurance-related questions you may have.
Prior to treatment, we encourage you to take the lead in contacting your insurance company to better understand your plan benefits. To help you start with this we have summarized key points about insurance coverage below. The first question to ask with regard to our clinic’s services is if the specific plan you have offers infertility coverage, or coverage for fertility testing. The vast majority of plans fall into one of three categories when it comes to infertility coverage.
The plan provides no coverage whatsoever for infertility services.
Unfortunately this is often the case and means that you will be expected to pay at the time of service for any non-covered services.
The plan provides coverage for the diagnostic phase of infertility testing only.
In this scenario, the insurance plan will usually offer some coverage for a new patient consultation and generally offers some coverage for fertility testing. The treatment phase is not covered.
The plan provides coverage for the diagnostic testing phase and coverage for infertility treatment.
In these circumstances, coverage is provided for diagnostic testing and for some methods of infertility treatment. Understanding your individual coverage will help you anticipate whether or not a particular service with us is covered.
***Please be aware that the Reproductive Medicine Laboratory (RML) does not participate with insurance plans. RML provides Embryology and Andrology laboratory services for testing and treatment. All services provided by RML will be on a self-pay basis, and payment is expected at the time of service. As a courtesy, claim forms will be filed to your insurance company for covered services with a request to reimburse the insured directly.***
Additional Important Insurance Information:
Out of Network:
If Oregon Reproductive Medicine is out of network with your insurance plan you may have limited coverage through an out of network benefit. Our insurance specialists will check for out of network coverage as part of the insurance benefit determination process. The Reproductive Medicine Laboratory does not participate with insurances companies.
Medical Coding (Diagnosis):
Our physicians are specialists in Reproductive Endocrinology. If you are seeking care in order to achieve a pregnancy you can expect that most, if not all, of your visits will be coded (diagnosed) as infertility or infertility related.
Review of Claims:
Insurance companies have the right to review claims for proper reimbursement for up to three years after the claim is made. This means that reimbursements that were made in the past can be reversed. When this occurs, the insurance company can demand refund reimbursement from you or from our practice. Should an insurance company in the future deny benefits for services rendered in the past and thus request refund of payment to them, payment for the services becomes the responsibility of the patient.
It is your responsibility to:
-
Bring your insurance card and identification to every visit.
-
Obtain any necessary physician referral or pay at the time of service.
-
Remit payment for services not covered by insurance (co-payments, deductibles, non-covered services, etc.) at time of service.
-
All self-pay fees will be collected at time of service unless a treatment deposit has been paid in advance.
We will not become involved in disputes between you and your insurance company regarding eligibility, deductibles, co-payments, secondary coverage, non-covered services, etc., other than to provide factual information regarding medical services provided.
Special Information for Aetna Patients
Aetnagenerally requires that you self-register with their infertility line at 800.575.5999. Please call Aetna to determine if self-registration is required.
If you are scheduled for an Intrauterine Insemination (Artificial Insemination) treatment cycle you must call Aetna on day 1 of your cycle at 800.575.5999 to obtain authorization, if required. Failure to do so may result in a denial of insurance coverage, and you will be expected to pay out of pocket.
In Vitro Fertilization generally requires prior authorization. It is your responsibility to determine if an authorization is on file before beginning your treatment cycle. If you wish to proceed with treatment prior to obtaining prior authorization you will be expected to pay out of pocket.