Understanding Your Health Plan Benefits
Recent changes in requirements governing your health coverage give patients improved treatment choices and options. Knowing what your health plan covers will allow you to make informed decisions and make the most of your benefits. At Women’s Care, our patients come first. As a partner with your physician, nurse practitioner or certified nurse-midwife, you play an integral part in making decisions about your medical treatment and knowing that your best interests are being served.
Annual Exam, Mammography and Pregnancy Coverage
Regardless of your health coverage, you have access to the following services without a referral or prior authorization:
It is not necessary for you to obtain a formal referral or prior authorization from any managed care plan in order to receive these services.
OB/GYN as Primary Care Physician
If your health plan requires you to designate a participating primary care provider (also called a primary care physician), you may have the option of choosing your OB/GYN to fulfill that designation. Simply ask your OB/GYN if he or she qualifies as a primary care physician on your plan. If so, and you choose to have your OB/GYN serve as your primary care physician, inform your insurance provider of your decision.
Prior Authorization and Specialist Referrals
It is important to follow up with treatment within 30 days of getting prior authorization approval from your insurance company for special services, or your approval will expire. Once an insurance company has granted prior authorization for you to undergo a procedure, the prior authorization is binding for up to 30 calendar days, as long as your coverage remains in effect. If your coverage is terminated, prior authorization is binding for five days. If coverage is terminated five days before your prior authorized procedure is conducted, the plan cannot request a refund from you or the doctor.
You are entitled to a timely response when your primary care physician seeks approval for you to see a specialist. After receiving a referral from your primary care physician, your managed care plan must reply to the request within five days.
Medical Records Confidentiality
Sensitive medical records, and their release to insurance companies, are a concern to many patients. At Women’s Care, we are committed to maintaining patient privacy and keeping medical records confidential, under the full extent of the law.
Results of HIV tests may not be forwarded to anyone without your expressed written consent. Even if you have signed a generic medical release, HIV testing will not be included in the information we forward. If you choose to have HIV results released, you must specifically request it in writing and specify to whom you wish the results be released.
Similarly, genetic testing results are also protected. Patients undergoing genetic testing must sign an informed consent prior to the testing, must sign a form stating that their insurance company or third party payer may be billed for the testing and, if results are to be forwarded, to whom and for what purpose they are to be released. Current Oregon law protects patients from discrimination based on the results.
As part of our commitment to making our community healthier and more aware through education, this brochure gives an overview of referral and access issues commonly associated with women’s health care. It should not be viewed as comprehensive or as legal advice. For more information about your insurance coverage or about laws governing health care issues, please call our office, 541-686-2996, or contact:
The information in this brochure is provided by Women’s Care.
Douglas Austin, M.D.
Cristin Babcock, M.D.
Melissa Edwards, M.D.
Frederick Green, M.D.
Peter Hatfield, M.D.
Matthew Haugen, M.D.
Robert Jacobson, M.D.
Paul Kaplan, M.D.
Gary LeClair, M.D.
Tina Schnapper, M.D.
Jennifer Tufariello, M.D.
Heather York, M.D.
John York, M.D.
Susan Armstrong, C.N.M.
Susan Trezona, C.N.M.
Jeanne Merrick, F.N.P.
Annual Exam, Mammography and Pregnancy Coverage
Regardless of your health coverage, you have access to the following services without a referral or prior authorization:
- One annual preventive women’s health examination
- Follow-up care for conditions found during an annual exam
- An annual mammogram for women over 40 years of age
- Pregnancy care for women or dependent children
- A two-day hospital stay following a vaginal birth, or 4 day stay following a cesarean section.
It is not necessary for you to obtain a formal referral or prior authorization from any managed care plan in order to receive these services.
OB/GYN as Primary Care Physician
If your health plan requires you to designate a participating primary care provider (also called a primary care physician), you may have the option of choosing your OB/GYN to fulfill that designation. Simply ask your OB/GYN if he or she qualifies as a primary care physician on your plan. If so, and you choose to have your OB/GYN serve as your primary care physician, inform your insurance provider of your decision.
Prior Authorization and Specialist Referrals
It is important to follow up with treatment within 30 days of getting prior authorization approval from your insurance company for special services, or your approval will expire. Once an insurance company has granted prior authorization for you to undergo a procedure, the prior authorization is binding for up to 30 calendar days, as long as your coverage remains in effect. If your coverage is terminated, prior authorization is binding for five days. If coverage is terminated five days before your prior authorized procedure is conducted, the plan cannot request a refund from you or the doctor.
You are entitled to a timely response when your primary care physician seeks approval for you to see a specialist. After receiving a referral from your primary care physician, your managed care plan must reply to the request within five days.
Medical Records Confidentiality
Sensitive medical records, and their release to insurance companies, are a concern to many patients. At Women’s Care, we are committed to maintaining patient privacy and keeping medical records confidential, under the full extent of the law.
Results of HIV tests may not be forwarded to anyone without your expressed written consent. Even if you have signed a generic medical release, HIV testing will not be included in the information we forward. If you choose to have HIV results released, you must specifically request it in writing and specify to whom you wish the results be released.
Similarly, genetic testing results are also protected. Patients undergoing genetic testing must sign an informed consent prior to the testing, must sign a form stating that their insurance company or third party payer may be billed for the testing and, if results are to be forwarded, to whom and for what purpose they are to be released. Current Oregon law protects patients from discrimination based on the results.
As part of our commitment to making our community healthier and more aware through education, this brochure gives an overview of referral and access issues commonly associated with women’s health care. It should not be viewed as comprehensive or as legal advice. For more information about your insurance coverage or about laws governing health care issues, please call our office, 541-686-2996, or contact:
- The Oregon Insurance Division
Consumer Protection Unit
350 Winter St., N.E., Room 440-2
Salem, OR 97310
503-947-7984
888-877-4894 (toll-free message line)www.cbs.state.or.us/external/ins/
The information in this brochure is provided by Women’s Care.
Douglas Austin, M.D.
Cristin Babcock, M.D.
Melissa Edwards, M.D.
Frederick Green, M.D.
Peter Hatfield, M.D.
Matthew Haugen, M.D.
Robert Jacobson, M.D.
Paul Kaplan, M.D.
Gary LeClair, M.D.
Tina Schnapper, M.D.
Jennifer Tufariello, M.D.
Heather York, M.D.
John York, M.D.
Susan Armstrong, C.N.M.
Susan Trezona, C.N.M.
Jeanne Merrick, F.N.P.
