Frequently Asked Questions

Coinsurance is the percentage you are liable for after any applicable deductibles or co-payments. If your policy pays 80 percent of costs, your liability is for 20 percent coinsurance.

Do I need a referral from my primary care physician to see a specialist?

No. Our plans are open access. A referral is not required from your primary care physician. But, in order to receive the best benefit, be sure to use an in-network provider. You can confirm that a provider is in-network by visiting www.chcne-m.com and clicking "Find a Doctor." Or by calling the customer service number on the back of your ID card.

Do I need to pay my patient liability to Coventry Health Care?

No. The Explanation of Benefits that is sent to you after a claim is processed is not a bill. It is an explanation of how the plan benefits were applied to your claim. For payment or billing questions, contact the provider directly.

Do I have to wait exactly 12 months to get my next routine physical or mammogram?

No. Routine physicals are generally considered once per calendar year. Refer to your Benefits Document for additional information.

When does my plan start paying at 100%?

Depending on the type of service you received, an out-of-pocket charge may apply - for example, a co-pay, deductible or coinsurance payment. Once the out-of-pocket charge has been satisfied, the Plan will pay benefits at 100%. Some services, though, are specifically excluded from out-of-pocket and will not be reimbursed at 100% (for example, prescription co-pays). Check your Benefits Document for a list of services that do not apply to the out-of-pocket or call the customer service number on the back of your ID card for more details.

What qualifies as durable medical equipment?

Durable medical equipment can be rented or purchased, such as a wheel chair, CPAP machine or nebulizer. The benefits are based on medical necessity and cannot be for convenience. An exercise bike or hot tub, for example, would be considered convenience items and not medically necessary.

Why am I charged a co-payment for lab work sent to a hospital by my physician?

Each service has specific Plan benefits that apply according to the place and type of service. If labwork is sent to a hospital, it is considered an outpatient hospital service. Check your Plan benefits for lab services and discuss alternatives for lab processing with your physician.

Why was my routine mammogram not paid at 100%?

Routine mammograms are covered at 100%. Contact your physician to determine if appropriate diagnosis was submitted to the insurance company.

Why do you need my Medicare number?

When Coventry Health Care is the secondary carrier and your physician submits your claims to Medicare, they will be automatically sent to Coventry Health Care for processing if the Medicare number is updated in our system resulting in prompt claim processing.

Why do I need to enroll in Medicare Part B?

If a member is eligible for Medicare Part B but chooses not to elect the benefits, Coventry Health Care will handle claims as if Medicare Part B is primary and benefits will be reduced based on the estimation of Medicare Part B payment. This may result in additional out-of-pocket expense for you.