Insurance Policies

Understanding insurance policy coverage can often be confusing. Pacific Fertility Center’s financial consultants are available to work with our patients so they may receive the benefits their insurance company provides.

Plans vary considerably in coverage for infertility. Some plans cover diagnostic procedures only and some cover diagnosis and treatment, but only specific types of treatment may be covered.

For a more detailed discussion, please see our section called Understanding Insurance

Know your insurance policy

There are 3 main categories of insurance policies:

1. Private Idemnity

  • Any Doctor of Choice
    • May have a deductible, usually 80% -100% insurance reimbursement
    • 0%-20% of the physician’s fee is the patient’s responsibility

2. Preferred Provider Organization (PPO)

  • Services Rendered by a Network of Physicians Contracted with the Insurance Company
    • Deductible must be met before 80%-90% insurance reimbursement of their usual and customary fees
    • Patients’ responsibility: 0% - 20% of the usual and customary fees

3. a. Health Maintenance Organization (HMO)

  • Services Provided through Physicians Contracted with the HMO
    • Services must be requested by the primary care physician and authorized by the HMO
    • Co-pay ranges from $5 - $20 per service

   b. Individual Practice Association (IPA)

  • Services Provided through Direct Contracts with Independent Physicians
    • Services must be pre-authorized by the IPA
    • Co-pay ranges from $5 - $20 per service and 50% of contracted fees

Some plans allow for additional deductible, additional co-pay amounts, and additional waiting periods before reimbursement.

Know one’s coverage. Get a copy of the contract and/or the summary plan description. Plans usually list included and excluded services.

Determine exclusions. “Infertility services excluded” means neither diagnostic nor treatment is covered.

“Infertility covered, but no artificial insemination, nor assisted reproductive technology covered” usually means diagnostic procedures, surgery or monitoring of drug therapy may be covered.

Be an insurance advocate. One may need pre-certification, pre-determination or pre-authorization. Our financial consultants assist patients by providing insurance specific codes for the services to be rendered. We recommend that our patients request pre-determination in writing. 

  • Pre-certification: If a patient’s plan requires pre-certification, their benefits will not be paid if they commence treatment before obtaining the pre-certification from the insurance company.
  • Pre-authorization: Referral from Primary Care Physician or OB/GYN to Reproductive Endocrinologist must be pre-authorized by HMO/IPA.

Investigate infertility riders, which are now being added to basic coverage by some insurance companies. One may be required to register as an infertility patient and meet criteria set by the insurance company.

Submitting claims. Courtesy billing: The billing office can file claims to our patient’s insurance for any appointments for which they have paid, thus allowing the insurance company to directly reimburse them. If a patient submits on their own, they must retain all documentation of payment and attach to their claim. Again, remember with some companies one must pre-register to be eligible for reimbursement.

Keep the explanation of benefits (EOB), all receipts and all documents from the insurance company. These will be invaluable in the event that a patient receives denials and they need to appeal.

The Financial Coordinators at Pacific Fertility Center provide a valuable service to our patients. Together with our patient’s input we can avoid loss of benefits due and maximize their reimbursement.