It includes the phone numbers to call if you have any questions, including the number for the HMO s customer representative. Every plan has a different certificate because the benefits under each plan are different. To find out whether a specific service or supply is covered, look for the heading that applies to the situation. For example, if your child is brought to the hospital by an ambulance and then stays in the hospital as an inpatient, the coverage for the ambulance service may be different from the coverage for the hospital stay. You may be required to make a copayment for the ambulance service but not for the hospital stay.
Certificates usually have a section of definitions to explain words that have special meanings.
It is important that you use the definitions to best understand your coverage. If you do not call the HMO first, then it might not provide coverage and you could be required to pay yourself. The certificate tells you when you need to call for prior approval. You can also call your HMO s customer service department to find out whether prior approval is required. My contract provides more coverage for participating providers than nonparticipating providers.