Avoid Out-of-Pocket Costs for Labs and Tests
Labs and tests are a routine part of most doctor visits and are rarely questioned. Patients tend to assume that anything their doctor orders must be necessary for treatment and, therefore, will be covered by their insurance. However, this may not be the case.
The Health Plan covers only services that are deemed medically necessary, and this includes testing. Before completing labs or tests, you should know the steps you can take to better understand whether they are medically necessary so that you avoid having to pay for expensive tests deemed not medically necessary by the Health Plan
Talk to Your Doctor
Not all tests are covered by the Health Plan. This table lists common tests that are not. Click to enlarge the image.
Discussing with your doctor the details of any recommended labs or tests can give you a more accurate assessment of what the Health Plan might cover and what your out-of-pocket expenses may be. The information you gather can also better guide your next steps, which should include working with your doctor to contact the Health Plan as discussed in the Talk to the Health Plan section. You can begin the conversation with your provider using the three questions below:
- Why are these tests being ordered?
Although the answer to this question may seem obvious, medical providers order labs and tests for various reasons depending on your treatment and circumstances. When discussing this question with your doctor, listen for terms like “investigational,” “new” or “experimental,” and obtain assurances that the tests are being ordered to specifically address the symptom or condition that is being evaluated. Tests may not be considered generally accepted medical practice or part of professionally recognized standards of care and, therefore, will not be covered by the Health Plan. - How will these labs or tests affect my overall treatment plan?
When trying to determine whether tests or labs may be covered by the Health Plan, consider the explanation your doctor gives for how the results will be used. Seek to understand whether the results will directly determine the next steps of your treatment plan. - Is this a repeat test or a genetic test?
In the case of repeated tests or genetic testing, ask your doctor to contact the Health Plan to determine coverage. Repeating tests may be a routine practice for a given provider or facility, but the Health Plan may have a limit on how often a particular test can be performed to be deemed medically necessary. When it comes to genetic testing, although such tests have grown in popularity, they may be used for investigational or informational purposes only, which would not be considered medically necessary. For additional tests that are not covered by the Health Plan, refer to the table above.
Knowing the answers to these questions can prepare you for the next steps in understanding whether the tests being ordered for you are considered medically necessary and covered by your insurance. The Talk to the Health Plan section below discusses how to use such information to determine whether your provider should contact the Health Plan to request a predetermination.
Talk to the Health Plan
After talking with your doctor about the tests being ordered, you can request that your provider contact the Health Plan for an assessment of whether those tests are considered medically necessary. This voluntary request for information is called a predetermination and can help you estimate the coverage for the services.
A predetermination is a written analysis that informs you whether the lab or test being requested is covered and, if so, to what extent. It is not a preauthorization or guarantee of coverage but allows you to potentially avoid out-of-pocket costs later.
To start the predetermination process, your provider should submit the applicable medical records and a letter of medical necessity, including diagnoses and procedure codes for the services being considered, to the Health Plan Claims Department via fax at (323) 866-2351 or via email at hpclaims@dgaplans.org. After the information is reviewed by the Health Plan, you will receive a written response that assesses the medical necessity of the tests. If your provider has any questions about this process, the provider should contact the Health Plan at (323) 866-2200, Ext. 401.
