Today I contacted my health insurer to go over some policy changes they notified me by mail about for the upcoming year. After they answered my policy questions, I took this opportunity to ask them my standard question, “as a member of your health plan, how do I find out what my specific out-of-pocket costs are– before visiting a provider?”

Here is what I learned. This type of information is called a FORMAL PRICING REQUEST and consumers (health plan members) must obtain specific information from the provider and follow the outlined procedures below. Contact your provider’s office and find out:

1. Provider’s NPI #
2. The specific diagnosis code(s) for the procedures that will be provided (ICD-9)
3. The specific CPT code(s) for the services that will be provided
4. The amount the provider charges for these services
5. The location (place) of service. This could be lab, outpatient facility, office, hospital)

After the member has all this information from the provider, the member should contact the health plan’s benefits/claims department and be ready to answer all these questions. Within 48-72 hours after the request is made, the insurer will provide the member with a letter identifying the member’s out-of-pocket costs for the services. As a convenience, the insurance plan has offered to read the letter over the phone, rather than mail it out to the member. Contact the Benefits/claims department.

Happy New Year!