Find out if your transgender surgery can be covered by insurance, even if Dr. Rumer is not “in-network” with your insurance company.

If Dr. Rumer does not currently have an “in-network” provider contract with your insurance company (you will need to ask us if we are in-network with your specific insurance company), then you will need to determine whether your plan covers the procedure(s) you desire. In order to make this determination you will need to do the following:

1. Locate your “member’s services” phone number on the front or back of your insurance card.
2. Call that number and let your insurance company know that you are calling in order to see if specific procedure (CPT) codes with a specific diagnosis code are covered under your plan.
3. If the insurance company tells you that the doctor’s office should be calling for this, tell them that the doctor (Dr. Rumer) is a non-participating provider and out-of-state (if applicable, as we are located in Pennsylvania), so Dr. Rumer’s office cannot not make these calls.
4. You will need to provide them with a diagnosis code which is F64.1 (Gender Dysphoria).
5. You will then need to provide them with the procedure (CPT) code(s) that was supplied to you by our office. The CPT code (there may be more than one) will be supplied to you during your consultation. Feel free to contact us (online or by phone at 484-297-6172) for this code(s) if you don’t have it.
6. If they inform you the procedure(s) is a benefit covered by your plan, ask them what criteria you need to fulfill (i.e., how many letters do I need to provide and from which doctors, hormone therapy, etc.) to have the procedure(s) authorized.
7. Then ask them for a reference number for your call and a pre-authorization/certification point of contact and associated phone number. DO NOT START AN AUTHORIZATION!
8. Provide the information identified in steps 6 and 7 (above) to our office as soon as possible.
9. Once these steps have been completed, and you have supplied the required and acceptable therapist letters to our office, you may now schedule a tentative surgery date. Once your insurance company authorizes your procedure(s) we will then finalize your surgery date.
10. In order to schedule a surgery date you must pay us a non-refundable surgery scheduling administrative fee (check with us as this fee amount depends on the surgery type). If the insurance company authorizes your surgery and the surgery is completed, this fee will be refunded or applied to any copays, co-insurance, and deductibles for which you may be responsible.
11. Once your therapist letter(s) have been reviewed and approved by our clinical staff, and your fee received, we will schedule your surgery date. We will also submit a letter of medical necessity (LMN) to your insurance company for your surgery. Our submittal of the LMN letter will initiate the fee negotiations and subsequent authorization process between our office and your insurance company.
12. If by chance your surgery is denied by your insurance after we have submitted the LMN letter you will be notified. At this point you can either cancel your surgery, appeal the denial with the insurance company, or opt to pay Dr. Rumer’s and the facility fees yourself.
13. Please be aware that, even if your plan covers your surgery, you may be responsible for copays, co-insurance, and deductibles and any fee gaps not covered by your plan which you must addressed prior to your surgery date (no less than three weeks prior to that date). If you choose to self-pay for your surgery than we will require payment in full (minus the already paid administrative fee) no less than three weeks prior to your scheduled surgery date. You may reschedule your surgery one time, but the new date must be within six months of your original surgery date.