Admitted to Hospital for Observation is it Covered?
If you’re admitted to a hospital for observation and not for treatment of a specific ailment, are expenses covered?
Answer
Observation is covered on all plans, but rules must be followed as per the plans network and cost sharing. Pre-authorization may be required, but treatment isn't required for observation to be covered. As with anything like this you'll want to check with your insurer to make sure costs are covered and that services you are receiving won't go past your insurer's "allowed amount". Nothing about the ACA has changed the way observation is covered.
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Explain pre authorization and what if treatment is required
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On an HMO specifically pre-authorization would be getting a referral from the doctor and on any plan authorization from the insurance company. The insurer authorization is key, but the doctor authorization may be needed as well. It is dependent upon the plan and the insurer, but as a rule of thumb it’s always good to double check something will be covered and the allowed amounts (most the insurer will pay for a service and how many services can be obtained).
What do you do if you are in Emergency Department at midnight and you cannot reach anyone to get pre-auth … Yet your doctor insists you need to be admitted for observation?
So you do always want to check with your insurer, but in emergency situation you should be covered under all plans. There is some grey area on this, so another thing you can do is check your plan’s benefits sheet or simply contact your insurer ASAP and appeal if they try to not cover something.