Planning Your Checkup

Please read this page carefully before scheduling your check-up. You may obtain your check-up either in or out of US. Please review the medical chart to learn about routine preventive services are paid by the plan, and any limitations.

Example: Services such as labwork or a chest X-ray may be considered Routine Preventive care if coded as such by your provider

 

 

 

 

Obtaining Your Check-up Outside of US 

Submit claims to Meritain just like any other service incurred out of US

  • Mark each item as routine preventive if applicable.
  • If symptoms require follow-up testing or treatment, that is not part of your routine preventive care.
  • All claims paid out of US are paid at the higher network level.

 

 

Obtaining Your Check-Up in the US
  • For the highest level of coverage, use PPO providers in the US.
  • PPO providers will submit claims for you.
  • Please review the medical chart to learn which routine preventive services are paid by the plan, and any limitations. If you are in doubt, please contact Meritain.

 

 

How Claims are Coded

Providers in the US must code claims as either “Routine Preventive” or with a medical diagnosis code. Please discuss with each provider (doctor, lab, and any others) how your claims are coded, as this will affect your claims payment.

  • For example, if your doctor codes your labwork as routine preventive, it will be paid at 100% subject to other plan rules
  • If you receive a service which could be considered routine preventive, but your provider codes it with a medical diagnosis, it will be paid at 80% in-network or 70% out of network
  • Only the provider can change coding on a claim, and some providers are not willing to resubmit a claim once it has been processed

Exception: A colorectal screening will be paid at 100% whether it is coded as routine or diagnostic (once every 10 years beginning at age 50).

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Please Note: The information contained in this site is intended as a summary of benefits. It does not guarantee coverage. The Health Plan pays benefits for medically necessary services resulting from illnesses or injuries that are not work related, up to reasonable and customary limits. Even though a doctor recommends or performs a service for you or your covered dependent, this does not automatically mean the service is covered by the Plan. If you have any doubt about whether a proposed treatment or service is covered under the Health Plan, please contact the number shown on your ID card.