An ER visit, a $12,000 bill - and a health insurer that wouldn't pay. Prior authorization cannot be required for emergency situations, but if you need additional follow-up care, you may need to get it authorized by your insurer ahead of time. What your insurer's requirements are in terms of prior authorization for subsequent medical procedures that stem from an ER visit.If the guidelines don't seem clear, call your insurer to discuss this with them, so that you can understand what's expected of you in terms of the type of facility you should utilize in various situations (Anthem outlined the guidelines in a letter they sent to members in 2017, when their new rules took effect in several states ). If so, familiarize yourself with your insurer's definition of emergency versus non-emergency.
Whether your plan has a rule that would result in a claim denial for non-emergency use of the ER.The new federal rules that take effect in 2022 will eliminate surprise balance billing in emergency situations, but it's still less hassle to just use an in-network ER if it's just as convenient as an out-of-network ER. In addition, if there's more than one ER in your area, you'll want to determine which ones are in your plan's network and which are not, since that's not the sort of thing you want to be worrying about in an emergency situation. Whether your plan covers out-of-network care, and if so, whether there's a cap on your costs for out-of-network care.The deductible and out-of-pocket costs on your plan, and any copay that applies to ER visits (note that some policies will waive the copay if you end up being admitted to the hospital via the ER, and the charges will instead apply to your deductible-these are the sort of things you'll want to understand ahead of time, so call your insurance company and ask questions if you're unsure how your plan works).
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