What type of insurance plan do I have?
Your insurance company might tell you that you have one of the following plans: Health Maintenance Organization (HMOs), Prefered Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), Point of Service (POS), and indemnity insurance plans.
Somerset Medical Center is not in my network but my plan has out of network benefits.
- If I choose to go out of network, what do I have to pay?
If you chose to go out of network your insurance company will most likely pay 80% patient responsibility 20%, 70% patient responsibility 30%, 50% patient responsibility 50%, etc.
- What is the amount of my deductible?
The amount of your deductible depends on the plan you have and you can call your insurance company to confirm this.
Is this percentage based on usual, customary, and reasonable (UCR) schedules or on the actual charges?
Somerset Medical Center's Managed Care Department works diligently to obtain the most appropriate rates for patients. Rates represent usual, customary, and reasonable fees for our location.
Does my plan participate in any other preferred provider organization (PPO) networks that provide additional coverage?
Check your insurance card as one of the following networks may be listed: Multiplan, MagnaCare, Beech Street, PHCS private healthcare systems, Coventry (Health First). Listing of Managed Care Plans accepted at SMC
If my out of pocket expenses reach a certain amount, will the insurance carrier ever reimburse at 100%? If so does this mean that my claims will then be paid in full, or will I still be responsible for the difference between Somerset Medical Center's charges and UCR rates?
In today's limited resourced economy, insurance companies have cut back reimbursement on many levels. Typically the insurance carrier will not reimburse at a 100%. Needless to say, your rates and difference that will be owed are subsidized because Somerset Medical Center aims to provide its patients with as much assistance as possible. Accountability of the payor, member, physician/provider, and hospital are fairly reviewed and established.
Should I bring my insurance card with me to the hospital?
Yes, the information on your insurance card is needed for the hospital to file a claim with your insurance company or companies. When you register we will ask for information about your insurance coverage and have you sign a few forms. This registration process goes much faster when you bring your insurance information with you and understand what you plan entails.
Will the hospital file my insurance claim for my current visit?
Yes. The hospital will continue to submit claims to your insurance company for you. As insurance companies require more information, however, the accuracy of your records is extremely important. Registration will facilitate prompt and accurate submission of your health insurance claim.
I gave my insurance information to my doctor, why don't you have it?
Many physicians are independent contractors. Each physician maintains his or her own patient information and actually files a separate claim then the hospital does. Depending on your plan, address, and company, your benefit coverage may be different for a physician than it is for hospital services. For these reasons, physicians and the hospitals retain separate insurance information.
I'm covered under my insurance and my wife's. The deductible is less under my wife's insurance. Can you just bill her insurance and not mine?
Under a provision called Coordination of Benefits, the hospital is obligated to bill the insurance that would be considered primary for you. Any medical insurance for which you are the primary holder must be billed before any other medical insurance.
How do I follow up with my insurance company?
Your insurance company has a phone number for member services on the back of your card typically. If you do not see a customer service line to call you can always access the data necessary online at your specific company's website. The insurance company's SMC are contracted with and can be accessed are located on the Insurance Company's Accepted tab. Before you call have available your insurance card, date of service, facility name, original billed amount, patient name and claim number if applicable. Write down the name of the person you talked to at the insurance company. If the bill has not been paid, find out when the anticipated payment date is and ask what is needed. If the bill is not paid in the stated timeframe, follow-up with the insurance company again and if necessary, request to speak to a supervisor. Other key questions you should ask the insurance company customer service representative include the following:
- Have you received the hospital's bill for these services?
- Am I covered for these services?
- When will you pay the hospital for these services?
- What portion of this bill will I be responsible for paying?
- What is the status of the account? If paid, ask when and to whom.
Do I need to let my insurance company know that I'm going to be in the hospital? And what will they cover?
SMC encourages its patients to check with your insurance company or your employer regarding coverage. There are so many different types of insurance plans that it is hard for the hospital to determine if you need prior approval or notification for your hospital stay. Contact your insurance company or your employer with specific questions about what is or is not covered by your insurance plan.
How do I know if my insurance company will cover my visit or certain services?
Coverage varies with each insurance company. The hospital staff does not know whether a particular service will be covered. Medically necessary and appropriate services may not always be covered by your insurance contract. Please refer to your insurance member handbook or call your insurance company with questions.
Why didn't my insurance cover some services?
Insurance policies vary on what services are allowed (paid). Your particular policy may not cover a certain service or you may not have met your policy's deductible and/or coinsurance. Our insurance billing staff can help you with any questions. Please call them at the number listed on your statement.
How do I know if my insurance company will cover services provided by all professionals involved with my treatment?
Again we encourage you to check with your insurance company or your employer about this. Each professional needs to contract individually with insurance companies and the hospital does not know if each professional is contracted with your insurance company.
How will I know if my insurance company has paid my bill?
If there is a balance due from you after the insurance company has paid its portion, we will send you a statement. The statement indicates the amount that has been paid and any balance you are required to pay. This is your bill, you are required to pay this bill in full or to set up payment arrangements by contacting our financial counseling office via the email contact included in this website or by calling Patient Financial Services-Billing 908.685.2829.
What do I do if I disagree with how much my insurance company has paid on my bill?
If you have questions regarding the payment call your insurance company for an explanation of the payment. If the insurance company finds that an error was made, not the information and whom you talked to at the insurance company. Request an anticipated payment date and ask if they need anything to complete processing. If the insurance company feels the bill was paid correctly and you still disagree, find out from the insurance company what you need to do to file an "appeal" with them. Filing an appeal will not guarantee that the insurance company will pay more on your bill but the claim will be reviewed for reconsideration. | 
