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Please see my comments below in your email outlined in red.
As always, please note that any advice given is hypothetical in nature, and that claims adjudication relies on all information submitted at the time of submission.
Let me know if you need anything else!
_______________________________________
Can you please let me know what the coverage is for out of network medical expenses?
After 6 months when preexisting conditions are covered, can you please answer the following questions:
• My daughter has Crohn's Disease. Can you please double-check that is not an excluded condition?
I see no reason why it would be excluded
• Part of Crohn's treatment requires Remicade infusions. Can you please check if this is covered, and if so if it can be done in a hospital, or must be done in a doctor's office?
I see no reason why it would be excluded. It is approved by the FDA, and it’s use in this situation would seem to be appropriate. And I see no reason why administration
in either a hospital or a Dr’s office would be an issue.
• Does Remicade need prior authorization? At what point should we get the prior authorization, since she needs to get this treatment every 8 weeks?
No prior authorization would be required.
• Is there any chance that Remicade coverage could be canceled while my daughter is abroad
I see no reason why it would be.
• If Remicade is covered, is it possible to see where the policy states that it is?
Per the policy, we pay for:
12. Drugs which require prescription by a physician for treatment of a covered injury or illness, but excluding drugs: prescribed for the treatment of diabetes, replacement of lost,
stolen, damaged, expired or otherwise compromised drugs.
• Does the insurance pay provider/hospital on their own, or do we have to submit for reimbursement?
If it is an infusion situation, ordinarily the providers will submit a claim on their own RE: the charges.
As always, please note that any advice given is hypothetical in nature, and that claims adjudication relies on all information submitted at the time of submission.
Let me know if you need anything else!
_______________________________________
Can you please let me know what the coverage is for out of network medical expenses?
After 6 months when preexisting conditions are covered, can you please answer the following questions:
• My daughter has Crohn's Disease. Can you please double-check that is not an excluded condition?
I see no reason why it would be excluded
• Part of Crohn's treatment requires Remicade infusions. Can you please check if this is covered, and if so if it can be done in a hospital, or must be done in a doctor's office?
I see no reason why it would be excluded. It is approved by the FDA, and it’s use in this situation would seem to be appropriate. And I see no reason why administration
in either a hospital or a Dr’s office would be an issue.
• Does Remicade need prior authorization? At what point should we get the prior authorization, since she needs to get this treatment every 8 weeks?
No prior authorization would be required.
• Is there any chance that Remicade coverage could be canceled while my daughter is abroad
I see no reason why it would be.
• If Remicade is covered, is it possible to see where the policy states that it is?
Per the policy, we pay for:
12. Drugs which require prescription by a physician for treatment of a covered injury or illness, but excluding drugs: prescribed for the treatment of diabetes, replacement of lost,
stolen, damaged, expired or otherwise compromised drugs.
• Does the insurance pay provider/hospital on their own, or do we have to submit for reimbursement?
If it is an infusion situation, ordinarily the providers will submit a claim on their own RE: the charges.
