Ask Member Services

Posted on June 22, 2011

How do I handle emergency or urgent medical visits when you are out of your HNE coverage area?

Everyone loves summer. As we all know, in the summer we may plan vacations or visits to family and friends outside of our health plan’s coverage area. Summer also offers the perfect time to increase or change our daily routines – bike riding, sports, barbeques, and other activities. Along with the fun can come unforeseen accidents such as allergic reactions to bee stings, baseball injuries, swimmer’s ear infections—you name it, it can happen!

To help eliminate any concerns our members may have when these mishaps occur, we would like to clarify our guidelines on Emergency Room visits, or Urgent Care visits, while you are out of your HNE coverage area. You can take simple steps to avoid receiving a denied claim or a direct bill:

If you have a Health Maintenance Organization (HMO) plan, are out of the area, and have to use an Emergency Room:

1. Pack your HNE ID card!
2. Present your insurance card at the time of your visit. This will give the hospital the necessary information to submit your claim to HNE. If you have an Emergency Room copay, some hospitals may ask for this payment at the time of your ER visit; others may bill you after they have submitted your claim to HNE for processing. Our billing information is on the back of your HNE ID card. Emergency visits are processed according to your plan benefit – your member responsibility differs based on your plan coverage.
3. If you need to go the Emergency Room, it is not necessary to notify HNE of your visit. Please note that usually a visit to the ER related to dental issues is not covered.

If you have an HMO plan, and are out of the area, and have to use an Urgent Care facility:

You may be in need of medical care, but feel you don’t need the full hospital ER visit. In that case, HNE offers members the option to use either an Urgent Care facility, or, if available, to see an Out-of- Area provider.

Follow these easy steps, to get your Urgent Care visit covered according to your plan benefit coverage:

1. Pack your HNE ID card!
2. Call us! If you are out of the area, we want and need to hear from you with the following information:
   • Who are you seeing? – Doctor name, facility, address and phone number.
   • Why are you being seen? Allergic Reaction? Stomach Pain?
   • What is your date of service?
3. HNE enters an authorization for this service, and will cover your visit in most cases with your specialist copay. Your plan selection may differ; check your plan coverage to see if you may be subject to a deductible, or if you have a High Deductible plan.
4. Present your HNE ID card at the time of your visit, and give the provider the authorization number you have obtained. If you were not able to notify HNE prior to your urgent care visit it is important to notify HNE as soon as possible so an authorization can be entered. Urgent Care covers your initial date of service visit. Any additional follow up care, while still out of the area, has to be coordinated through your primary care provider (PCP) and needs prior approval through HNE.

If you would like further clarification on your benefit coverage, feel free to call us. We are here to help!

Enjoy a safe, happy summer!

Categories: Summer 2011