Understanding Your Insurance
Health insurance coverage is a major concern for all patients and is often misunderstood in today's chaotic age where health care reform is constantly evolving new rules, regulations and terms. It is Somerset Medical Center's mission to serve our community and make access to information easy and friendly.
You may be wondering if medical care at Somerset Medical Center (SMC) will be covered by your insurance policy. The following information has been developed to help patients understand insurance coverage at SMC and to make the process of becoming a patient here as easy as possible.
To ease your admission to the hospital, we will begin the paperwork as soon as your doctor informs us of your admission date or at time of your arrival. We recommend that you familiarize yourself with the type of coverage provided by your health insurance and that you know whether you've met all necessary terms. If you belong to a Health Maintenance Organization (HMO) or a Managed Care Organization (MCO), be sure your primary care provider is aware of your impending hospitalization and is prepared to submit a referral to authorize your admission. On the day of your arrival, you may be required to pay a deductible or co-payment. In certain cases, an admission deposit (based on your estimated length of stay) may be required. The pre-admission coordinator will discuss the deposit with you.
To Our Patients
For many patients and their families, an inpatient stay or same-day visit includes filling out unfamiliar forms and answering financial and insurance questions. The information below and the phone numbers that follow can help with this process.
Additional Bills
In addition to your bill from Somerset Medical Center, you may receive other bills for services rendered during your stay from the following areas: Associated Radiologists, Inc.; Somerset Pathology Associates; and Emergency Medical Associates. If you used the services of a physician in the Vascular Laboratory or the Department of Anesthesiology, you also will receive separate physician bills.
Clinical Laboratory
Your clinical laboratory charge will be in two parts. A hospital technical charge, which is included in your hospital bill, covers the cost of equipment, supplies and technical personnel who prepare the specimens. You will receive the second part of your bill from Somerset Pathology Associates for the pathologist's professional services. If you have any questions regarding this bill, please call 908-203-5992.
Radiology
Your radiology charge will be in two separate parts. A hospital technical charge, which is included in your hospital bill, covers the cost of equipment, supplies and technical personnel. You also will receive a bill directly from Associated Radiologists, Inc., for the professional services of the radiologist. If you have any questions regarding this bill, please call 732-968-1500.
Anesthesiology
If your hospitalization included the services of the Department of Anesthesiology, the charge for equipment and supplies will be included on your bill. In addition, you will receive a separate bill for the professional services of the anesthesiologist.
Emergency Department
If you used the Emergency Department, you will receive a separate bill from Emergency Medical Associates for services rendered by the emergency care physician. If you have questions, please call 800-345-0064.
Vascular Laboratory
If you used the services of a physician in the Vascular Laboratory, you will receive a separate physician's bill.
If you have any questions about any of the bills you receive, please contact a Patient Financial Services representative at 908-685-2833.
Benefits
Many insurance companies limit the number of days of hospitalization that they will cover, and may limit certain hospital services. Even if you have insurance, you still may be responsible for payment of deductibles, co-insurance, private room charges and telelphone charges. Most insurance companies require the patient to notify them at the time of admission. Please contact your insurance company for complete information about your benefits and coverage.
Charity Care/Reduced Charge Care
Somerset Medical Center will provide services without charge or at a reduced charge to New Jersey residents who cannot afford to pay and who meet specific income, assets and other eligibility criteria. If you think that you may be eligible, please contact our patient financial counselors at 908-685-2829 or 908-203-5992.
Denials and Appeals
Somerset Medical Center maintains an Appeals Department to review non-coverage decisions related to your inpatient stay. In most cases, the patient is not financially responsible for denied charges. Patients continue to remain responsible for deductibles, co-insurances or other charges outlined in your health care insurance policy.
A member of your Appeals Team may request your consent to appeal these non-coverage decisions on your behalf. You also retain the right to appeal directly to your insurer.
Registered Nurse Appeals Coordinators and support staff are available to answer questions about the appeal process. For more information, contact Care Management at 908-685-2953.
Insurance Identification (I.D.) Card
To enable Somerset Medical Center to bill your insurance company directly, you will be asked to provide your insurance identification (I.D.) card. In the event of an emergency, the card should be presented as soon as possible following admission. You also will be asked to provide any claim or referral forms required by your insurance company.
Somerset Medical Center is a participating hospital provider in numerous major managed care organizations.
Note: Failure to provide accurate and current insurance information and required referrals when you are admitted could result in penalties or a reduction of benefits by your insurance company.
Medical Necessity
This term refers to those services, as defined by your insurance company, that are medically appropriate in an inpatient hospital setting.
Pre-certification
Most insurance companies require pre-certification, or approval of admission before a scheduled hospital stay. It is the hospital's policy to contact a patient's insurance company to verify benefits and to initiate our pre-certification requirements. However, it is your responsibility to pre-certify your scheduled admission by contacting your insurance company before coming to the hospital.
Emergency admissions must be "pre-certified" by contacting your insurance company as soon as possible (usually within 24 hours).
Note: Failure on your part to pre-certify with your insurance company could result in a reduction of benefits, or in some instances, a denial of payment by your insurance company for your hospital stay.
Second Surgical Opinions
Many insurance companies require a second surgical opinion prior to approving surgery. Please check your insurance policy to determine if this is required.
Questions?
If you have further questions, please do not hesitate to call any of the following departments for assistance.
Admitting
908-685-2957
Inpatient Pre-Certification
908-704-3775
Outpatient Pre-authorization Questions
908-685-2420
Patient Financial Services
Billing: 908-685-2829
Credit: 908-685-2833
Care Management (Case Managers/Social Workers)
908-685-2953
Pay your bill online using our Online Business Office
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