We get it. You have a nagging pain in your back that just won’t go away, so you go see your doctor, who sends you for an X-ray. Unfortunately, the X-ray doesn’t show a thing, so the next step might be a CT-scan or even an MRI, and you may even have to see a specialist depending on the test results.
You think you’re all set, but then the doctor says, “We’ll call you to set up an appointment after we get prior approval from your insurance company.”
Wait. What? You think, “I can barely stand up and now I have to go through this red tape?”
Yes, you probably do.
Community Health Options understands that getting medical care is nerve-wracking enough, so you won’t need a referral for the specialists, even though the specialist may require one from your doctor. But Members do need Prior Approvals for certain services and prescriptions before getting treatment (Prior Approvals are also sometimes called Prior Authorization, Precertification or Preauthorization).
While it might seem like getting approval delays care, Community Health Options, as a nonprofit insurer, uses Prior Approvals to understand its Members needs and to facilitate care. Clinicians rely on evidence-based care guidelines to approve the care Members need, while protecting against the care they don’t. Importantly, approval ensures that a Member’s health plan will cover the service or procedure.
Community Health Options Chief Medical Officer Dr. Lori Tishler calls it “utilization management with heart. Our goal is to get someone what they need, so we’re constantly looking for ways to make things easier for patients and providers.”
When "No” means “Yes”
In some cases, clinicians at Community Health Options may even suggest more care than the initial request. For example, a request for a certain kind of outpatient behavioral health care was denied because the Community Health Options team saw a need for inpatient care and worked with the provider to get that higher level of care delivered.
In almost every case, the company responds to urgent requests within 24 hours and more routine requests within 72 hours, but usually less. Requests may be denied if clinicians at Community Health Options need more information about the need for a certain procedure.
And in 2023, the company dropped Prior Approval requirements for about 5,000 codes primarily across three categories—ultrasounds, obstetrics ultrasounds and services related to treating fractures. A code review committee continues to review and revise Prior Approval requirements.
A right to appeal
Members and providers always have the right to appeal a Prior Approval decision, whether for a medical benefit or prescription. In many cases, additional information helps to move things along, and sometimes providers will talk to an independent doctor for a final decision about the best solution.
Members with questions or concerns about Prior Approval can call the Community Health Options’ Maine-based Member Services team number on the back of their Member ID card from 8 a.m. to 6 p.m., Monday through Friday.
Buying health insurance probably isn’t among the more exciting purchases you’ll ever make. But like it or not, it’s one of the most important each year. So, we want to help you get it right.
When you start shopping for health insurance, likely the first thing you’ll check is the price, or monthly premium. This makes sense, but just like buying a car or a house, price doesn’t tell the whole story.
You might think of the premium—the monthly charge for coverage—as a “sticker price.” But that’s only the beginning of what you’ll pay because most plans include copays, coinsurance and deductibles, which all add up to how much you pay out-of-pocket annually. You can learn more about those costs here.
It’s important to understand the benefits you’ll use because they directly impact how much you might pay to reach an annual maximum out-of-pocket limit, when insurance takes over and pays all your costs. Generally, the less you pay for insurance, the higher your deductible—and the more you’ll pay out-of-pocket as you use more services. So, knowing what you might need will help you limit out-of-pocket costs and maximize your benefits.
You’ll also want to understand types of coverage and be sure your carrier offers a comprehensive network. For example, an “HMO,” which stands for health maintenance organization, gives you access to preferred providers; but you’ll need to stay in-network to get coverage. A second popular option, a “PPO,” or preferred provider organization, costs more but affords the freedom to use out-of-network providers at a slightly higher price.
Within each type of plan, deductible costs are designated by Bronze levels, which cost the least, and Silver, Gold and Platinum levels which cost more, but have lower deductibles. You can learn more about those levels here.
As you compare plans, you’ll get information about costs and coverages, but you’ll also see which plans offer services like wellness programs, dental or eye exams, or chronic care programs to support you along the way. Unique to Community Health Options, for example, is a care management program that partners with community services to support well-being, such as providing transportation to appointments or even meals for someone who is recovering at home.
You might consider a Silver, Gold or Platinum plan if:
You might consider a Bronze plan if:
While costs can weigh heavily when selecting a plan, it’s most important to choose coverage that fits your needs. And you might find help paying for insurance thanks to the passage of the 2022 Inflation Reduction Act, which extended Affordable Care Act premium tax credits. To find out if you’re eligible, visit CoverME.gov, Maine’s online Health Insurance Marketplace. For information or to get help choosing a plan, you can also call Member Services at (855) 624-6463. For quick tips on what to look for, how to get help with, or how to use a health plan, follow @communityhealthoptions on TikTok.
