Financial Matters Checklist
Make sure your insurance plan and specific product is accepted at UMass Memorial
✓ See UMass Memorial contract list and contact your insurance company
Ensure UMass Memorial is in-network for your plan
✓ Contact your insurance plan for your benefit coverage
✓ Always check with your health insurance plan before getting care to make sure you understand your covered benefits and costs.
✓ The insurance plans listed are accepted by UMass Memorial Health Care. Some physicians may accept different insurance plans than our hospitals. To make sure your physicians accept your insurance, please check with their office before you schedule an appointment.
✓ Many insurance plans are now considered “tiered” or limited network plans and have different levels of cost-sharing depending on where you go for care. The information found using our website should be used as a reference, but it is important that you check with your health insurance plan to see what level of coverage you will receive at a specific hospital. Even if you see your insurance plan listed, additional referrals or authorizations may be required. Some services may not be covered by your insurance coverage at every location. The level of coverage provided to you is determined by your insurer.
✓ Also, many insurance plans may use other companies to cover certain services such as behavioral health (mental health) or transplant-related services. Please contact your insurance plan or employer to understand any specific benefits.
Obtain approval from your insurance company
✓ Check with your insurance company for coverage and any pre-authorization requirements for care.
Obtain a referral from your primary care physician (PCP)
✓ Check with your insurance company to see if a referral is required to see a specialty care physician. If so, contact your primary care physician one week prior to your appointment to ensure the referral is on file or you may be required to reschedule your appointment.
Make sure you have the financial means to cover your visit
✓ For example, you may need to pay for unmet deductible, copayments, co-insurance, unmet out-of-pocket expenses, self-pay deposits, transportation.
Precertification and Prior Authorizations
Your UMass Memorial doctor will decide which procedures, tests and other consultations you may need. However, many health plans require pre-certification and sometimes predetermination of medical necessity prior to care being rendered. In addition, certain services may not be a covered benefit for some plans. Investigating coverage requirements and limits can take up to seven weeks, and some services require pre-certification staff to supply photos and medical necessity information to your insurance company.
For example, services that may require pre-certification include outpatient and inpatient hospital services, observation services, invasive procedures, CT, MRI and PET scans, and colonoscopies.
Patients are responsible for knowing the pre-certification requirements of their health plan. UMass Memorial highly recommends that you contact your insurance company to determine benefits and coverage for the UMass Memorial Health Care location at which you plan to be seen.
• 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 network or authorization from the plan.
• Plans that require prior authorization or pre-certification may provide only a reduced insurance payment if not previously authorized. In such cases, the patient will be financially responsible for more — possibly all — of the services provided.
• A pre-service deposit may be required for nonauthorized visits.
• To avoid paying a pre-service deposit or experiencing either denial of payment or a reduction of benefits, UMass Memorial Health Care highly recommends you contact your insurance carrier prior to services to determine plan requirements or limitations to receiving care at UMass Memorial Health Care location at which you will receive services.
Please contact your physician’s office to verify that UMass Memorial office has received your prior authorization.
Prior to scheduling a second-opinion consultation at UMass Memorial Health Care
- Understand any second-opinion requirements with your insurance company. The insurance company can tell you whether it covers second opinions and whether any precertification requirements apply.