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How direct pay works for individual and group members: FAQ

We take care of the details so you can focus on getting better

If one of our members falls ill and needs medical care while living or working overseas, the last thing they want to worry about is how they’re going to pay for treatment. International private medical insurance (iPMI) policies are designed to take that stress away, offering health care providers (such as doctors and hospitals) the assurance that they’ll be paid for their work, and allowing our members to receive the right treatment, whenever and wherever they need it.

Some iPMI policies require patients to make payment before, or very soon after, receiving treatment, then submit a claim to their insurer for reimbursement. But for many people this presents understandable concerns, particularly around whether the costs of their treatment will be fully covered when their claim is submitted. This is where a strong direct pay network comes into its own, and also where preauthorisation can help.

The quality of the health care providers we work with is as important to us as it is to our individual members, our group clients and their employees. As such, we require our network of health care providers to have in-depth knowledge and maintain compliance to country-specific provider selection guidelines to ensure the quality and safety of the services performed. 

At Aetna International, we aim to help our members find the right health care provider to ensure a safe, high-quality care experience. We also aim to provide access to direct pay whenever possible so members don’t have to pay for services upfront and seek reimbursement. Our network is set up to meet the current and longer-term health care and budgetary needs of our members, and clients — organisations with international employees. This means that our members often won’t need to worry about paying for treatment up front. Two examples of these are direct pay and preauthorisation. We have 1.9M providers in our global network of doctors, hospitals, walk-in clinics, and pharmacies. Internationally, more than 200 countries and territories. This FAQ explains what direct pay means and how it works.

What is direct pay?

Aetna International works with a global network of health care providers. If a member is living or working overseas and needs treatment, they can go to any provider in that network and — depending on the type of cover they have — we can pay the provider directly. Direct pay can be available worldwide, at clinics, hospitals and surgeries, whether your client is receiving treatment as an outpatient, or admitted to hospital as an inpatient.

How does direct pay benefit members?

Many health care providers ask for payment before or during treatment. If a member visits a health care provider in our direct pay network, we’ll pay the provider directly. This means our members don’t have to make a payment and then claim the costs back at a later date, or worry about whether their claim will be covered.

Can members use direct pay for all their health care needs?

Direct pay is designed to help manage expenses for high cost treatments when visiting a health care provider within our direct pay network. If your employee suffers a medical emergency, needs surgery, or complex treatment requiring hospitalisation, direct pay could be available, subject to an excess payment. But if they were visiting a local doctor for a routine check up, or a lower cost health care expense, they would need to pay the provider directly and submit a claim.

Is direct pay available everywhere?

Almost everywhere.  At Aetna International, we have a broad network of health care providers around the world, and have direct pay arrangements with those providers. We do not operate or offer health care support within countries under US and EU sanctions. Currently these include: Crimea, Cuba, Iran, North Korea, North Sudan and Syria.

What is preauthorisation?

Preauthorisation is also known as:

  • precertification
  • authorisation
  • certification
  • prior authorisation
  • Guarantee of payment (GOP)

If a member becomes ill while overseas, their proposed treatment and associated costs might need to be authorised by Aetna International before it can be received. This is known as preauthorisation, and it allows us to ensure you’re covered, protecting you from unexpected or unnecessary costs.

Preauthorisation applies to certain services, including, but not limited to:

  • Single treatment or service that costs more than USD  500 or equivalent
  • Medical evacuation
  • Inpatient or daycare treatment admission
  • Psychiatric treatment
  • Prescription for more than three months’ supply of drugs. 

If a member is seeing a provider in our network, the provider might seek preauthorisation on the member’s behalf.  If the member isn’t seeing a provider in our network, or if the provider isn’t going to secure preauthorisation for the member, they member will need to contact us by calling the number on the back of their Member ID Card.

How does preauthorisation benefit my clients?

Preauthorisation protects employees and members from unexpected costs, as Aetna International will have validated the likely cost of treatment before it begins and we will have agreed to cover it. Preauthorisation also brings peace of mind that the future doesn’t hold any unpleasant surprises. Medical treatment can be stressful for many individuals — especially when accompanied by fiscal uncertainty — and reducing that is a great comfort to many. 

Is preauthorisation different if my client is being treated at a health care provider inside the direct pay network?

If a member is being treated at a provider in the direct pay network, they might organise preauthorisation for the member. Otherwise, the member will need to call the member helpline before their treatment begins, so our Care and Response Excellence (CARE) team can preauthorise their treatment.

Will you always preauthorise treatment?

Our aim is to make sure our members receive the best possible health care outcome. In some cases, a treating doctor may have a treatment proposal that our CARE team and their independent consultants thinks can be improved upon. In those circumstances, we’ll put forward a second opinion, and ensure our member gets access to the specialists they need to receive that treatment, wherever they are in the world.

What if my client doesn’t request preauthorisation before receiving treatment?

If our member or their health care provider doesn’t request preauthorisation, we may (in some circumstances) only be able to cover a portion of the treatment the member receives. The exception here is if the member is receiving treatment as a result of a medical emergency. In those situations we need to be notified of treatment within 24 hours.

How do members access direct pay?

It a member falls ill or suffers an injury overseas, their first step should be to find the nearest health care provider in our direct pay network. They can find this information in the Health Hub section of our website. If there’s an Aetna International network provider within reach, we recommend going there, as members will automatically benefit from direct pay benefits, subject to any excess payments. If there isn’t a network provider close by, they can visit an alternative facility and call the member assistance line to organise preauthorisation of any required treatment.

Members must present the health care provider with their Aetna International Member ID Card, accompanied by an additional form of ID such as a driver's licence.

Is there anything else members should know?

Not all treatments are covered on all policies. Before receiving any treatment, members should ensure it’s specified as a benefit in their policy documents. If they have any doubts about this, they should call the Member Services team to check they’re covered.

If you have any further questions on direct pay, preauthorisation, or any other part of an Aetna International policy, you can contact our Member Services team 24/7, 365 days a year. Contact details are here.

If you’re an employer or broker looking for international Private Medical insurance for clients or staff, you can call us to discuss your needs. Get the right telephone number for your area, here.

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