Insurance & Coverage
Insurance and What It Covers
Insurance coverage depends on your specific plan, the reason for the visit, network status, referrals or prior authorization, and the services performed.
Whether your insurance pays depends on your particular plan, why you are coming in, whether we are in your plan’s network, whether you need a referral or approval beforehand, and what is actually done on the day.
Insurance: the essentials
The short version
Plan participation can change; contact the office and your insurer to confirm current network status.
This changes over time. Ring the office and ring your insurer to check where things stand now.
Depends on the patient’s plan and the medical necessity/benefit rules for the service.
Depends on your plan, and on whether your plan counts the treatment as medically necessary.
Elective cosmetic services are often not covered by health insurance; individual benefits must still be verified.
Treatments chosen to change how you look are usually not covered. You should still check your own plan.
Some plans/services may require a referral or prior authorization before care is covered.
Some plans want a referral, or want to approve the treatment in advance, before they will pay.
Copay, deductible, coinsurance and non-covered charges depend on the plan and services rendered.
Your share depends on your plan and on what is done. It can include an excess, a fixed fee per visit, a percentage, or the whole cost of anything not covered.
How do I check whether my visit is covered?
How do I check whether my visit is covered?
Verify both network status and the specific benefit. Being “in network” does not automatically mean every service is covered, and a covered benefit may still involve deductible, copay or coinsurance.
Check two separate things: that we are in your plan’s network, and that the particular treatment is covered. Being in network does not mean everything is paid for, and even something that is covered can still leave you with an excess or a share to pay.
- Call the member-services number on your insurance card or use the plan’s current directory.
- Confirm the exact practice/provider identity required by the plan, not just the office specialty.
- Ask whether the planned visit/service needs a referral or prior authorization.
- Ask how deductible, copay and coinsurance apply to the service.
- If the service is cosmetic/elective, ask whether it is excluded from coverage.
- Ring the member services number on your insurance card, or look us up in your plan's own directory.
- Check the exact practice and doctor name your plan needs, not just that we are a skin clinic.
- Ask whether this visit or treatment needs a referral, or approval from them in advance.
- Ask how your excess, your fixed fee per visit, and your percentage share apply to it.
- If it is a cosmetic treatment, ask whether your plan excludes it altogether.
What do common insurance terms mean?
What do the insurance words mean?
Understanding a few basic terms makes benefit checks easier. Your plan’s Summary of Benefits and Coverage and member documents provide the plan-specific definitions and amounts.
A few words come up again and again, and knowing them makes the phone call much easier. Your plan’s own summary document gives you the exact definitions and amounts that apply to you.
| Network | Doctors/facilities that have a specific participation arrangement with the health plan |
|---|---|
| Deductible | Amount you may need to pay for covered care before the plan begins paying according to its rules |
| Copay | A fixed amount that may be due for a covered visit/service |
| Coinsurance | A percentage of the allowed cost you may owe after applicable plan rules |
| Prior authorization | Plan approval that may be required before selected services |
| Referral | A plan-required direction from another clinician for selected specialist care |
| Non-covered service | A service the plan does not include as a benefit under the applicable circumstances |
Network The doctors and hospitals that have an agreement with your health plan.
Deductible An amount you may have to pay yourself each year before the plan starts paying its share.
Copay A fixed amount you may owe for a visit or a treatment.
Coinsurance A percentage of the cost you may owe once the plan’s rules have been applied.
Prior authorization Approval the plan may require before it will cover certain treatments.
Referral A note from another doctor that some plans require before they will cover a specialist.
Non-covered service Something your plan simply does not pay for in these circumstances.
Health insurance card and dermatology appointment planning materials
An insurance card, and the things worth sorting out before a skin appointment.
Why can medical and cosmetic dermatology be billed differently?
Why are medical and cosmetic treatments billed differently?
Insurance generally evaluates whether a service meets the plan’s covered medical-benefit rules. A treatment performed primarily to change appearance may be considered cosmetic/elective even when a similar device or procedure is used for a medical indication.
Insurance asks whether a treatment counts as medical care under your plan’s rules. Something done mainly to change how you look can be counted as cosmetic, and therefore not covered, even when the same machine or procedure is covered when it is done for a medical reason.
- The diagnosis and purpose of treatment matter; the device name alone does not determine coverage.
- A consultation does not guarantee that a proposed procedure will be covered.
- Ask the office for current self-pay or cosmetic pricing when applicable, because fees and treatment plans can change.
- What matters is why the treatment is being done, not the name of the machine.
- Having a consultation does not mean the treatment discussed will be covered.
- Ask the office for current prices if you are paying yourself, because prices and plans change.
What should I ask before my appointment?
What should I ask before my appointment?
Ask enough questions to understand the administrative requirements before the visit, but remember that a pre-visit estimate or benefit quote is not the same as a final insurer claim decision.
Ask enough to know what is expected of you before you come in. But remember: an estimate given beforehand is not the same as your insurer’s final decision on the bill.
| Is the specific provider/practice currently in network? | Which insurance details/referrals should I bring or complete before the visit? |
|---|---|
| Is the type of visit/service a covered benefit? | Does this service usually require authorization in your workflow? |
| What deductible/copay/coinsurance applies? | What is the practice policy for non-covered or cosmetic services? |
| Is a referral/prior authorization required? | Whom should I contact with billing/coverage questions? |
Are this practice and this doctor currently in my network?
What insurance details or referrals should I bring or sort out beforehand?
Is this type of visit covered by my plan?
Does this usually need approval in advance?
What excess, fixed fee or percentage will I owe?
What is the policy for anything not covered, or for cosmetic treatments?
Do I need a referral or prior approval?
Who do I contact about a bill or about coverage?
Questions patients ask
Which insurance plans does the practice accept?
Which insurance plans do you take?
Contact the office and your health plan to confirm current participation. Network contracts can change, and being in network does not guarantee that every service is covered.
Ring the office, and ring your health plan, to check where things stand right now. These agreements change, and being in network does not mean every treatment is paid for.
Does being in network mean my treatment is covered?
If you are in my network, is my treatment covered?
No. Network status and benefit coverage are separate questions. Your plan may cover the visit but not a specific procedure, or may apply deductible/copay/coinsurance rules.
Not necessarily. Those are two separate questions. Your plan might cover the visit but not a particular procedure, or might still charge you an excess, a fixed fee or a percentage.
Are cosmetic treatments covered by insurance?
Does insurance cover cosmetic treatments?
Elective cosmetic services are often excluded, but the exact answer depends on the plan and why the service is being performed.
Usually not. But the real answer depends on your plan and on why the treatment is being done.
Do I need a referral?
Do I need a referral?
Some plans require referrals for specialist care and others do not. Check your plan before the visit.
Some plans require one to see a specialist and some do not. Check yours before you come in.
What is prior authorization?
What does prior authorization mean?
It is a health-plan process that may require approval before selected services are covered. Authorization does not always guarantee final payment because other benefit rules can still apply.
It means your plan has to approve certain treatments before it will pay for them. Getting that approval still does not guarantee payment, because other plan rules can apply as well.
Can the practice guarantee what my insurance will pay?
Can you tell me exactly what my insurance will pay?
No. The office can help with available administrative information, but the health plan makes the final coverage and claim decision under your benefits.
No. We can help with the paperwork and tell you what we know, but your health plan makes the final decision on what it pays.
Talk it through with a physician first.
Every plan starts with an assessment of your skin, your anatomy and what you actually want to change.
