How does health insurance plan reimbursement work?

How does health insurance plan reimbursement work?

Imagine the following situation: you have a family doctor, with which to query for years, but that is not part of the  network accredited by your new health plan. Or you need emergency care in a place where there are no doctors or hospitals referenced.

What happens in these cases? We have to change doctors or bear the costs, often quite high? You can obtain the refund of the consultation and other amounts paid for medical services?

By law, you can only claim a refund of the amount paid for an appointment with a doctor who does not belong to the network accredited by the health plan in some specific situations. Therefore, it is important to be careful not to embitter an unnecessary loss!

In this post, we have prepared a guide to the most common questions and answers on the subject. Thus, it becomes easier to choose the health plan that best meets their needs and demand the fulfillment of their rights by the operator. Let’s check?

1. In what situations you can request consultation refund?

The health plan must reimburse the user the amounts paid for consultations in two situations:

  • emergency , which is characterized by risk of death or irreparable injury attested by a physician responsible for the care;
  • urgency , which is held after a personal accident or due to a complication in pregnancy.

In addition, the refund can only be requested when there is no on-site of care, doctor, accredited clinic or hospital or when access to them is not possible – for example, when the institution refuses, for some reason, provide the necessary patient care.

When the consultations do not fall into these situations, they are called elective and, by law, the health plan is not obliged to make a refund if there is no express provision in the contract signed between the parties.

2. All health plans accept refund requests?

If you did not hire a health plan in the mode called free choice, the only accepted applications for refunds are those provided for by law and described above.

So it is important to stay well aware at the time of signing the contract with a healthcare provider. Before buying, make sure the plan you choose is the one that best fits your needs and your family and ensures that benefits you consider important, such as the right to use doctors and hospitals outside the accredited network.

If your health plan is free choice, you may request a refund of queries every time they use medical services, noting, of course, periods of shortages and procedures provided in your contract.

In such cases, the operator has 30 days after receipt of complete documentation for payment of the amounts.

3. What is the deadline to ask the query refund?

If you want to request a refund query, browse to the application within 30 days after service. Although some plans establish longer terms of up to one year, others may refuse to make the payment if the request happens after that.

The documents required to request repayment vary from one health provider to another and should be informed in advance to policyholders through its service channels.

In general, it is necessary to present the invoice and a document signed by the doctor containing the diagnosis and specifying the services provided. Therefore, if possible, it is best to learn about the specific requirements of your plan before scheduling a consultation or any other medical facility.

It is also important to remember that it is the duty doctor and the institution where the services were provided to provide such documentation to the patient within a reasonable time and without unnecessary bureaucracy.

4. The amount to be reimbursed is the same as I paid for consultation?

This is a question that depends largely on the health plan chosen by you. Arrangements can establish the payment of a percentage value at each visit or a fixed value, which can be equal to or less than you paid out.

In general, health care providers maintain a fixed table refund, which varies according to the contracted plan.

However according to the ANS, the National Supplementary Health Agency , the institutions are not required to attach this table in their contracts. Therefore it is essential to thoroughly check the reimbursement amounts before closing the deal.

Although they are not required to provide the table with the contract, according to Procon , institution dedicated to the protection and defense of consumer rights, the insured has the right to be informed clearly and prior way on the reimbursement amounts for medical appointments and other procedures.

If you have not checked the table before signing the contract, seek the your carrier’s service channels and ask for the amounts to be reimbursed and the calculation method used before performing the service.

This way you will know if the refunded amount fully cover the query value or be required to spend an additional value. This makes it easy to schedule any expenses and avoid surprises.

If the health plan refuses to provide this information or excessively hinder their access to it, know that you have the right to request a full refund of the amount paid by the query.

The repayment table offered by each agreement must be adjusted based on the same indices used in increasing tuition. If not, it is the user ‘s duty to report your service to the relevant bodies, such as the NSA and Procon.

Like to understand how the query refund procedure in health insurance companies? So do not forget to share this post on your social networks so that more people can know their rights and choose a plan that meets your needs!


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