The insurance aspect of infertility treatment can be confusing. We have provided this
information in an effort to help clarify the basic categories and coverage available to
many patients. These categories of coverage pertain to IVF as well as other forms of
fertility treatments and procedures. The financial consultants at Pacific Fertility
Center are available to work with our patients so they may receive the benefits their
insurance company provides.Plans vary considerably in coverage for infertility.
Some plans cover diagnostic procedures only and some cover diagnostic procedures and
treatment, but only specific types of treatment may be covered.
There are 3 main categories of insurance policies:
1. Private Indemnity
Any Doctor of Your Choice May have a deductible:
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Usually 80%-100% reimbursement. 0%-20% of the Physicians' fee are your responsibility. |
2. Preferred Provider Organization (PPO)
Services Rendered by a Network of Physicians Contracted with the Insurance Company
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Deductible Must be met before 80%-90% insurance reimbursement of their usual and customary fees.
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Patients responsibility: 0%-10% of the usual and customary fees.
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Services provided by physicians outside of network are not subject to usual customary fees. |
3. Health Maintenance Organization (HMO)
a. Basic HMO
Services provided through Physicians controlled by the HMO
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Services must be requested by the Primary Care Physician and authorized by the HMO.
Co-pay ranges from $5-$20 per service. Some plans allow 50% co-pay for infertility
services. |
b. Individual Practice Association (IPA)
Services provided through direct contracts with independent physicians.
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Services must be preauthorized by IPA. Co-pay ranges from $5-$20 per service.
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Some plans allow for additional deductible, additional co-pay amounts, and additional waiting periods before reimbursement. |
Know your coverage:
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Get a copy of the contract and/or the summary plan description. Plans usually list
services which are included and services which are excluded from the plan.
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For your convenience, we have provided a form letter to request information about your fertility coverage. You may fill the letter out online, print it and mail to your insurance company. Please click on the link "Insurance Form Letter" in the banner at the top of this page. |
Determine exclusions:
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"Infertility services excluded" means neither diagnostic procedures nor
treatment is covered.
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"Infertility covered, but no artificial insemination, assisted reproductive technology covered", usually means diagnostic procedures, surgery or monitoring of drug therapy may be covered. |
Be your own insurance advocate:
You may need pre-certification or predetermination or preauthorization. Our
consultants will assist you by providing insurance-specific codes for the services to be
rendered.
We recommend that you request predetermination in writing.
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Pre-certification: Your benefits will not be paid if you commence treatment
before obtaining the pre-certification from the insurance company.
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Preauthorization: Referral from your Primary Care Physician or OB/GYN to a Reproductive Endocrinologist must be preauthorized by HMO/IPA.
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Investigate infertility riders, which are now being added to basic coverage by some insurance companies. You may be required to register as an infertility patient and meet criteria set by the insurance company. |
Submitting your claims:
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If possible your Physician will process the claims directly, but if you must submit on
your own, request documentation from your Physician and attach to your claim.
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Keep your explanation of benefits (EOB), all receipts and all documents from the insurance company. These will be invaluable in the event you receive denials and you need to appeal.
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Our consultants provide a valuable service to you and together with your input we can avoid loss of benefits due and maximize your reimbursement.
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