AboutLinda Woolsteen Expertise I can help you with questions about health insurance. If you feel your insurance company is mistreating you. Are they telling you they are checking eligibity, pre-existing, etc. Or you just don`t understand how your insurance works or don`t understand what a PPO is.. I can help you.
Experience
Past/Present clients One company I worked for I was the underwriter for the Academy of Medicine of Cleveland and the Ohio Bar Association. I was also a supervisor of our customer service department.
Question my son is going to spend the rest of the summer with his father in virginia. i live in ohio and am worried that if he needs medical services while hes there if he will be covered
Answer Hi,
All depends on what type of policy you or his father has that he is insured under.
Do you have MMO (Medical Mutual of Ohio)? Kaiser? Summa? Do you have an HMO or PPO? If you have a PPO plan then it all depends on who your repricer is. First Health is a PPO repricer. First Health (last I knew of) and probably still is was a national PPO network. Therefore, you should be able to find providers (doctors, hospitals, etc.) that are in network, no mater what state, that are in network with First Health.
If you have a HMO like Kaiser then of course you have to go to Kaiser Providers/facility.
I would, ahead of time, call your Insurance company and/or review on their website as to what hospital's and doctors are in network.... just incase something should happen and let his father know in advance that if something should happen to him you want him taken to XYZ hospital (if at all possible) or XYZ doctor if at all possible in order to save the bother of you money in the long run.
Then again some insurance companies like Aetna are national and you are more likely to find providers in network in other states. For example, my daughter goes to college in Florida and woke up one morning after a vigorous hair brushing, lol and couldn't move her neck. I called Aetna (our plan is based out of Ohio) and found a doctor innetwork with Aetna right across the street from her college.
If all else fails and he ends up going to an out of network provider and in the end claims are processed as out of network. You can always appeal to see if they will help you out.
Always, remember..... on PPO plans.... just because the doctor you are seeing MAY be in-network.. that does not mean that the hospitals he/she is affiliated with ARE in-network as well. Also, just because the Hospital is in network... does not mean that ancillary providers such as ER doctors, Radiologists, labs, Anesth. are in network. But.... if the hospital is in network, the insurance company should process the ancillary providers claims as in network since you have no control over those providers, typically they will still be subject to R/C or U/C whichever you prefer and you still may be responsible for any charges over and above the R/C or U/C amounts. (Reasonable/Customer or Usual/Customary).
Your best bet is to call & speak to your insurance company and finding out about hospitals/doctors that are in network or where he may go, ahead of time so you are prepared. Make sure you get the Customer Service Rep's name and it doesn't hurt to call again later to and double check. Where I worked for 10 yrs, I often heard other Customer Service Reps and other people in our company giving different answers to things.
