Verify the exact plan and place of care
- Use the exact plan name, network, member ID, and group number from the card or portal.
- Confirm the legal billing name, address, facility NPI, and place of service when available.
- Ask whether the setting is hospital inpatient, hospital outpatient, ambulatory surgery center, urgent care, doctor office, or emergency department.
- Save the representative name, date, time, and call reference number.
Verify separate billing groups
- Surgeon or specialist group
- Anesthesia group
- Radiology or imaging interpretation
- Lab and pathology
- Pharmacy, infusion, rehab, home health, or DME suppliers
Verify approval and cost exposure
- Prior authorization, referral, medical-necessity review, and center-of-excellence rules
- Deductible, copay, coinsurance, out-of-pocket maximum, and out-of-network exposure
- Written estimate and what the estimate excludes
- Appeal path if a claim is denied or delayed
Questions to ask
Is this exact facility in network for my exact plan?
Is the doctor group separately in network?
Does this service require prior authorization or referral?
Could anesthesia, imaging, lab, pathology, rehab, pharmacy, or DME bill separately?
Can you document this answer and give me a reference number?