Frequently Asked Questions

Maintenance care means that the care that you are receiving is no longer improving your medical condition.

If you believe your claim has been processed incorrectly, please contact our Customer Services Department. If you do not agree with the denial of a claim, please send an appeal in writing to Assurant Health, Correspondence Department, P.O. Box 624, Milwaukee, WI, 53201-0624. Note any extenuating details, include any documentation pertaining to the appeal, and keep a copy for your records.

The amount of time it takes to process a claim depends on the information submitted. In general, you should receive an Explanation of Benefits within 3-4 weeks. If additional information is required to process a claim, we will notify you, and the claim could take longer to process.

Yes. Our fax number is (414) 224-0472.

Refer to the back of your health insurance ID card for claims submission information.

Usually, the pharmacy will submit prescription claims for you. Otherwise, to order claim forms, simply contact Medco Health at the number on your prescription ID card, or visit www.medcohealth.com.

Please submit the claim as soon as you can. Assurant cannot consider any claim received more than 15 months after the date of service.

Your preauthorization vendor will send you a telegram that will explain if the procedure and/or hospital stay is approved or denied. If you are being hospitalized, the specific number of days approved will also be provided.

Your health insurance ID card shows the preauthorization telephone number, and a full listing of which services require preauthorization can be found in your health insurance policy. Please follow the preauthorization procedure in order to maximize your benefits.

In most cases, preauthorization is a requirement for services listed in your health insurance policy. Please review your health insurance policy for details.

A predetermination of benefits is a written request for verification of benefits. We review these requests based on policy provisions, and send an explanation of your potential health insurance benefits. You may request a predetermination before your medical procedure, although a predetermination of benefits is generally not necessary.

Preauthorization is when we are notified in advance of a surgery or hospital stay, and is required for most policies. The requirements can differ from policy to policy, but the purpose of preauthorization is to determine if a hospitalization or surgery is medically necessary, and how many days of hospitalization are warranted. Your health insurance ID card shows the preauthorization telephone number, and a full listing of which services require preauthorization can be found in your health insurance policy. Please follow the preauthorization procedure in order to maximize your benefits.

Assurant Health determines reasonable and customary amounts on facility (i.e., hospital) charges. If you wish to dispute a reasonable and customary amount allowed for a facility charge, please call them at the toll-free number listed on your EOB statement.

There is a specific reasonable and customary amount allowed in your geographic area, and this is the amount allowed by your policy. Anything over the reasonable and customary amount would be your responsibility.

Reasonable and customary (R&C) is the dollar amount allowed for a particular service. The reasonable and customary amount for charges is determined by Assurant Health using your geographic area.

Family out-of-pocket expense is your deductible and coinsurance added together, for your whole family. In other words, it is the maximum you will have to pay per person, per calendar year, no matter how many members of your family need health insurance benefits.

Individual out-of-pocket expense is your deductible and coinsurance added together. In other words, it is the maximum you will have to pay — per person, per calendar year — in deductibles and coinsurance.

A copayment is the amount you pay for each prescription drug or PPO physician office visit.

Coinsurance (also known as Rate of Payment) is the percentage of covered expense you are responsible for after you have met your deductible. For example, if your coinsurance is 20% up to $5000, Assurant Health will pay benefits at 80% of covered expenses up to $5000. Then Assurant Health will pay 100% of your covered charges, up to the policy maximum. You are responsible for the 20% amount that Assurant Health does not pay.

The calendar year begins January 1st and ends December 31st each year.

A health insurance deductible is the amount of covered expense you must incur and pay each calendar year before we will pay for covered medical expenses. This is for each individual, each calendar year. Expenses that are not covered by your health insurance policy will not be applied to your deductible.

A non-smoker discount is a reduction in the health insurance premium amount for our policyholders who lead a healthier lifestyle by not using tobacco products.

A Special Class Premium is an additional premium amount you pay for your health insurance policy due to a medical condition you might have (for instance, high blood pressure).

Unless specifically excluded by your contract, you are covered for the benefits listed in your health insurance policy. All health insurance policy provisions apply, including medical necessity and reasonable and customary.

Each time you fill a prescription, present your ID card at a participating Medco Health pharmacy. Once you satisfy your annual deductible, you pay the copayment specified on your drug card. After applying any discounts, deductibles, or copayments, the pharmacy will submit your claim electronically. To locate a participating pharmacy, simply contact Medco Health at the number on your prescription ID card, or visit www.medcohealth.com.

Medco Health is the vendor Assurant Health uses to process your prescription drug claims. In other words, they are an outside company we contract with to administer your prescription drug benefits on our behalf.

A Maternity rider is an amendment to a medical policy that provides coverage for normal childbirth.

The Doctor's Office Copayment Option is an optional benefit that provides 100% coverage for all covered reasonable and customary charges for an office visit to any physician after a copayment. Copayments do not apply toward satisfying the deductible or out-of-pocket maximums.

The Accident Medical Expense rider provides benefits for injury due to a covered accident. AME benefits are administered per injury/accident, instead of per calendar year. After AME benefits are paid, your annual health insurance deductible, coinsurance and emergency room copayment (if appropriate) will apply.