| At HNE, we understand that health care is always changing. Because of advances in technology, many outpatient surgical procedures that used to be done at a hospital facility are performed in a doctor's office. Often, this is both more convenient and cost effective. In response to this change, HNE changed the copayment for these types of services on July 1, 2005 for our fully funded plans. Now, members pay the same copayment for outpatient surgical services whether they get them at a hospital, surgical center, or doctor's office. The copayment for outpatient surgical services performed at a hospital or surgical facility is no longer the same as the copayment for acute hospital care.
HNE covers the following services under the outpatient surgical services benefit:
- Outpatient or ambulatory surgery and related services
- Certain procedures, such as sigmoidoscopies, colonoscopies, arthroscopies, needle aspirations, and biopsies
Some outpatient surgical services are simple, minimally invasive, and/or minor in terms of the time, preparation, or expertise needed to perform them. Others are more complicated or involved and/or may require the skills of a clinical specialist.
Some services may be performed in an outpatient facility or physician office. The outpatient surgical services copayment is applied based on the type of service, not where it is performed.
In general, Members do not pay an outpatient surgical services copayment for:
- Services that are simple, minor, or involve a small, localized area of the body
- Services that involve closed treatment
- Services that require only local anesthesia
- Biopsies that are not extensive or invasive
- Injections
- Imaging guidance
Members do pay an outpatient surgical services copayment for:
- Services that are complicated, clinically complex, deep, or involve an extensive area of the body
- Services that involve open treatment
- Services that require general anesthesia
- Scope procedures (such as endoscopies and colonoscopies)
- Some IVF procedures
To find out if the outpatient surgical services copayment applies to a specific procedure, please contact Member Services at 413-787-4004 or 800-310-2835.
NOTE: Certain outpatient surgical services require Prior Approval by HNE. These are listed in the Explanation of Coverage. HNE will approve these services only if they are medically necessary covered services and meet HNE's clinical review criteria.
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