Usizo uma kungekho abahlinzeki abasenkundleni abaseduze noma abaqeqeshiwe
I-exception yegebe yenethiwekhi iyithuluzi lezinkampani zomshuwalense wezempilo esebenzisa ukukhokhela izikhala kwinethiwekhi yabo abahlinzeki bezempilo abanenkontileka. Uma umshuwalense wakho wezempilo enikezela okuhlukile kwegeythi yenethiwekhi, okuyaziwa nangokuthi i-gap ehlukile, ikuvumela ukuba uthole ukunakekelwa kwezempilo kumhlinzeki wangaphandle wenethiwekhi ngenkathi ukhokhela imali ephansi yokuhlanganyela ngezindleko zenethiwekhi.
Yeka ukuthi i-Network Gap Exception Yeyiphi
Ngaphandle kokuhlukile kwekhasi lenethiwekhi, uma ubona umhlinzeki wangaphandle, uzokukhokha okungaphezu kwalokho ozokhokha uma ngabe usebenzisa umhlinzeki we-in-network. Uma unayo i- HMO noma i- EPO , uhlelo lwakho lwezempilo ngeke lukhokhe imali eyodwa yezindleko zokunakekelwa kwakho ngaphandle kwenethiwekhi ngaphandle uma uthola ithuba lokungena kwenethiwekhi. Uma unesiphakamiso se- PPO noma i-POS, uhlelo lwakho lwezempilo luzokusiza ukuthi ukhokhele ukunakekelwa kwakho okuphuma ngaphandle kwenethiwekhi. Kodwa-ke, imali yakho yokubambisana, imali yokukhokha kanye ne-copayments iyoba yikhulu kakhulu uma usebenzisa umhlinzeki ngaphandle kwenethiwekhi uma usebenzisa umhlinzeki we-in-network.
Ukucela ukungena kwe-ingekha ye-inthanethi kusuka kumshuwalense wakho wezempilo kubuza ngokusemthethweni umshwalense ukuthi akhuphe ukunakekelwa okuvela kumhlinzeki ongaphandle kwe -inthanethi ngesilinganiso senethiwekhi . Uma ngabe umshuwalense wakho unikela ngokungafani kwekhasi lenethiwekhi, uzokhokha imali ephansi ye-inthanethi, i-copay, noma i-coinsurance yalolo hlobo oluthile lwezokunakekelwa kwenethiwekhi.
Kungani Isiqephu Se-Network Gap Singasisiza
Okokuqala, qaphela ukuthi uhlelo lwakho lwezempilo ngeke luzimisele ukunikeza ithuba lokungena kwenethiwekhi. Kungumsebenzi owengeziwe kubo, futhi kungase kuphele kube kubiza nabo. Kodwa-ke, uma uhlelo lwezempilo lungenalo umnikezeli we-in-inthanethi endaweni yakho noma uma lowo mhlinzeki engakwazi ukuhlinzeka ngemisebenzi yokunakekelwa kwezempilo oyidingayo, akulungile ukukhokha ukwabelana ngezindleko eziphakeme ngoba nje Uhlelo lwezempilo alukwazi inethiwekhi enikezelayo ngokugcwele.
Ngakho-ke, ama-insurers anganika ithuba lokungena kwenethiwekhi ukuvumela ukuba uthole ukunakekelwa okudingayo kumnikezeli wangaphandle ngaphandle kokukhokha okungaphezu kwalokho okufanele ukhokhe.
Izizathu Ungathola I-Export Gap Exception
Awunakwenzeka ukuba unikezwe umahluko wegebe wenethiwekhi ngaphandle kokuthi okulandelayo kuqinisile:
- Ukunakekelwa okukufunayo kuyisibonelelo esihlanganisiwe futhi kunesidingo sempilo .
- Akukho mnikezeli we-in-inethiwekhi okwazi ukuhlinzeka isevisi oyidingayo ngaphakathi kwebanga elifanele. Uhlelo ngalunye lwezempilo luzichaza ngokwalo ukuthi ibanga elilinganiselwe liyi. Kwezinye izinhlelo zezempilo, kungenzeka kube ngamamayela angu-50. Kwezinye, kungaba ibanga elikhulu noma elincane.
Uma isimo sakho sifana nalezi zidingo ezingenhla futhi uthola umhlinzeki wangaphandle wenethiwekhi ohlangabezana nazo zonke izidingo zakho, ungathumela isicelo esikhungweni sakho somshuwalense wezempilo ngenxa yokungafani kwenethiwekhi. Kwezinye izimo, umhlinzeki wangaphandle we-network angase azimisele ukwenza lokhu kuwe; kwezinye izimo, kuzodingeka ukwenze ngokwakho.
Kufanele ucele ukukhetha kwegebe lenethiwekhi ngaphambi kokuthola ukunakekelwa . Uma ulinda kuze kube yilapho usuqaphele, uhlelo lwakho lwezempilo luzocubungula isimangalo njengengaphandle kwenethiwekhi futhi uzokhokha ngaphezulu.
Isimiso se-Network Gap Sisebenza Ngaphandle Kokuhlinzeka Isevisi eyodwa Ecacile
I-exception yegebe yenethiwekhi ayikuniki i-blanche card ukubona umhlinzeki ongaphandle kwenethiwekhi nganoma iyiphi isevisi oyifisayo, nganoma isiphi isikhathi ufisa.
Esikhundleni salokho, uma umshuwalense unikela ngokungafani kwenethiwekhi, okuhlukile ngokuvamile kuhlanganisa kuphela isevisi ethile ehlinzekwe ngumhlinzeki othile ngaphandle kwenethiwekhi phakathi nesikhathi esilinganiselwe.
Yini Ozoyidinga Ngesicelo Sakho Esingaziwayo
Ukwaziswa oyokudinga lapho ucela ukungena kwegeyethi kuhlanganisa:
- Ikhodi ye- CPT noma i-HCPCS echaza isevisi yezempilo noma inqubo oyidingayo.
- Ikhodi ye- ICD-10 echaza ukuxilongwa kwakho.
- Ukwaziswa koxhumana naye ophuma ngaphandle kwenethiwekhi.
- Ibanga losuku lapho ulindele ukuthola khona insizakalo eceliwe. Isibonelo, kusuka ngoFebhuwari 1, 2018, kuya kuJulayi 31, 2018.
- Amagama kwanoma yikuphi abahlinzeki be-in-network of the specialty efanayo endaweni yakho kanye nencazelo yokuthi kungani umhlinzeki in-inethiwekhi engakwazi ukwenza isevisi.
Ukuze uqiniseke ukuthi okuhlukile kwegeyethi kunamasevisi okudingayo, thola amakhodi we-CPT, amakhodi we-HCPCS, namakhodi we-ICD-10 avela kumhlinzeki wakho ongaphandle kwenethiwekhi. Uma lokhu kunzima ngoba awukwenzanga ngempela ukulingana nomhlinzeki okwamanje, udokotela owakutshele angakwazi ukukunikeza amakhodi wezokwelapha adingekayo.
Ukuchaza ukuthi kungani Umnikezeli Wakho Wokungena Ngenethiwekhi Engeke Awuke
Uma kukhona abahlinzeki be-in-network of the specialty efanayo njengomhlinzeki wangaphandle wenethiwekhi ocela ukungena kwekhasi lenethiwekhi, uzodinga ukuchazela inkampani yakho yomshuwalense ukuthi kungani ungakwazi ukusebenzisa inethiwekhi umhlinzeki.
Nasi isibonelo. Ake sithi udinga ukuhlinzwa kwezindlebe futhi ucela ukungena kwe-ingebe yenethiwekhi ukumboza i-otolaryngologist ngaphandle kwenethiwekhi ukwenza lo msebenzi. Noma kunjalo, kune-otolaryngologist ye-in-network ngaphakathi kwendawo yakho. I-otolaryngologist ye-in-network ikhulile, inesandla sokuthuthumela, futhi ngaleyo ndlela ayisenzi ukuhlinzwa. Uma ungasebenzi kahle ekuchazeni uhlelo lwakho lwezempilo ukuthi kungani i-otolaryngologist ye-in-network ingakwazi ukunikeza isevisi oyidingayo, kungenzeka ukuthi isicelo sakho sinqatshelwe .
Okufanele Ukwenze Uma Isicelo Sakho Sikhishwa
Ungayeki ngisho noma isicelo sakho sinqatshelwe. Shayela inkampani yakho yomshuwalense wezempilo ukuze uthole ukuthi kungani. Ngezinye izikhathi, izicelo ziphiwe ngenxa yezizathu ezilula njenge:
- Umshuwalense akakwazanga ukuxhumana nehhovisi lokuhlinzeka ngaphandle kwenethiwekhi.
- Umshuwalense ucabanga ukuthi kukhona abahlinzeki be-inthanethi abakwazi ukunikeza isevisi efanayo.
- Umshwalense akanayo ikheli lakho elifanele futhi ngaleyo ndlela ucabanga ukuthi uhlala eduze nabahlinzeki be-inthanethi kunakho.
Zonke lezi amaphutha zingasuswa. Uma usuqonda ukuthi kungani isicelo senqatshiwe, ungafaka isikhalazo leso sinqumo noma uthumele isicelo esisha somkhiqizo esibandakanya ulwazi olwengeziwe lokuqinisa isicelo sakho.