Treatment cost estimator terms of use

Reliance on Price Estimates and Other Information: Reliance on information provided on this Site is solely at your own risk except as may be otherwise required by law. You should exercise independent judgment before applying any information provided on this Site to your own financial and health management needs, or otherwise relying on other information. As noted below, the cost estimates included in this Service are generated by HealthTrio and Harvard Pilgrim. The cost estimates provided in this Service are not a guarantee of payment or benefits.

The estimates are based on Harvard Pilgrim’s contracted rates for the selected services with in-network providers and a usual and customary (UCR) fee schedule for such services with out-of-network providers. Your actual cost may be higher or lower than the estimate for various reasons. 

The results displayed are estimated costs based on information available to Harvard Pilgrim and HealthTrio at the time the request is made, including any facility fee, copayment, deductible, coinsurance of other cost-sharing requirements for any medically necessary covered item or service. Your plan accumulations are valid as of the date of the estimate. Deductible and out-of-pocket maximum accumulation status may change based on in-process claims. Any third party payments made toward your cost share, including copayment assistance, are not included in the calculation of your deductible and out-of-pocket maximum. The actual amount you will be responsible to pay may vary due to unforeseen services that arise out of your proposed admission, procedure or service. Actual charges and out-of-pocket costs may also be different if the admission, procedure, or service is different than the type quoted, your coverage changes, the provider bills the services differently, or if there are unforeseen services that were not included in the estimate because they were not apparent based on the information requested. Because all cost estimates are specific to the service, provider, and place of service searched, we recommend that you review the service description in the estimate results for accuracy and discuss further with your provider if necessary.

For items and services that are recommended preventive services under federal law (the Public Health Services Act, § 2713), an in-network item or service may not be subject to cost-sharing if it is billed as a preventive service, however, the estimate may reflect a cost-share if it cannot be determined whether the requested item or service will be billed preventive or non-preventive by your provider. When care is provided by an in-network provider, you are responsible for any applicable cost share as stated in the terms of your benefit document. If you choose to see an out-of-network provider (a provider who is not in the network applicable to your plan), depending on the specific terms of your plan, your services may not be covered and/or you may be financially responsible for any charges. Please also be aware that out-of-network providers may bill you for the difference between the billed charges and the sum of the amount collected from the health plan and from you in the form of a deductible, copayment, or coinsurance amount (this difference is referred to as “balance billing”). The cost-sharing estimate does not account for these potential additional balance billing amounts. Emergency care is covered at the authorized level of benefits, regardless of whether you see an in-network or out-of-network provider.

As stated above, the cost estimate is not a guarantee that benefits will be provided for the item or service. The cost estimates displayed do not constitute authorization for any admission, procedure or treatment; such authorization must be obtained separately if required for the service(s). Benefits are also subject to your eligibility on the date of service. Your plan eligibility is based on information made available from various sources, such as an employer group or state exchange, and our systems may not reflect your actual status. For more information, please review the “Estimates are not Authorizations/Not Responsible for Coverage Determinations” section below.

Before making any health care treatment decision, you should check on any pieces of information of importance to you (i.e., that your doctor or facility is still in the Harvard Pilgrim provider network, or accepting new patients, as well as the provider's quality metrics). If you have any questions about a cost estimate, and/or benefit, referral, or authorizations, please call a member specialist at the number on your membership card.

Estimates are not Authorizations/Not Responsible for Coverage Determinations: This Service will provide assistance to help you understand your health care coverage and payment options. Statements, interpretations, advice or opinions by this Service regarding health care coverage and/or payment options are solely provided to assist you with your decision making and are based on review of current information available regarding your plan. The accompanying information available on this Site should not be construed as representing your Harvard Pilgrim's medical policies or clinical programs. The ultimate decision on whether a procedure is covered, and to what extent coverage may be provided, rests solely with Harvard Pilgrim and not with HealthTrio.

Nothing on this site guarantees eligibility, coverage, or payment, or determines or guarantees the benefits, limitations or exclusions of your coverage. Use of this Service in no way increases or decreases the benefits under your health plans or employer's benefit plan. For a complete description of the details of your coverage, please refer to your coverage documents. If there is any conflict or discrepancy between the content on this Site and your coverage documents, your coverage documents will control.

All claims will be processed when received according to your specific plan provisions. You will be responsible for the cost of procedures or services not covered by your plan. Pre-authorizations or referrals are required for certain benefit plans and certain healthcare providers. Refer to your benefit plan to determine whether these requirements apply to you. Please note that the cost estimates displayed through this Service do not constitute authorization for any admission, procedure or treatment. Authorization must be obtained separately if required.

Not Professional Advice: While cost and quality information are emphasized within this tool, it is important to note that many other factors impact the selection of providers. These may include established provider relationships, network considerations, primary care referrals, and/or benefit plan design. This Service seeks to provide members with additional information to enable them to make an informed decision about their healthcare. It is broad in scope and intended only to assist you in the organization of and decision-making relating to your health care coverage and payment options. It is not intended to provide legal, medical, healthcare coverage, tax or financial advice. HealthTrio is not itself, or an agent of, a health care provider, health plan, broker or tax or financial advisor.

Your personal situation is unique, and any information and advice obtained through the Service may not be appropriate for your situation. Accordingly, before making any final decisions or implementing any financial or health care strategy, you should consider obtaining additional information and advice from your health care provider, health plan, advisor, broker or others who are fully aware of your individual circumstances.

The health-related information and resources in the Service is made available to you solely for informational purposes and is intended to supplement, not substitute for, the expertise and judgment of your healthcare professional. It does not constitute medical advice and is not a substitute for professional medical care. Nothing on this site is intended to be used for medical diagnosis or treatment, including information regarding which drugs or treatment may be appropriate for you. None of the information on this Site represents or warrants that any particular drug or treatment is safe, appropriate, or effective for you. Always seek the advice of your health care provider before beginning any new treatment or if you have any questions regarding a medical condition. If you are ill or need immediate medical care, please contact your health care provider or, in an emergency, call 911 or go to the nearest medical facility.

Educational Resources: This Service may make available self-care informational services which provide general medical and health information. These communications and resources are not comprehensive medical texts and do not include all the potential information regarding the subject matter. These communications and resources are for general educational and informational purposes only and should not be relied upon as a substitute for patient-specific medical diagnosis and treatment or construed, directly or indirectly, as the practice of medicine or dispensing of medical services by HealthTrio or Harvard Pilgrim. Such information is not a substitute for seeing an appropriate healthcare professional for medical treatment. We make no warranty as to the content of these materials or the information contained therein.

Changes to Site: You acknowledge that while we make an effort to keep you updated on important changes, such as by notifying you at login that a new Terms of Use is available for review, the Site and Services may be changed, modified or updated at any time for any reason without direct notice to you and information may not always be up to date. We may also make modifications or changes in, or discontinue products, services or programs offered at any time with or without notice. We reserve the right to remove, screen, edit, or reinstate content, including third party and user content, from time to time at our sole discretion and without notice to you. For example, we may remove a review if we believe it violates our guidelines. We have no obligation to retain or provide you with copies of content, nor do we guarantee any confidentiality with respect to user content, except with respect to PHI as stated above.

¹ For members enrolled in Massachusetts fully-insured plans, the cost estimate amounts are binding subject to the conditions and limitations further explained herein.

With the Service, HealthTrio may be accessing health plan information about you or your minor dependents provided by Harvard Pilgrim (“Account Information”). HealthTrio does not review the Account Information for any purpose, including but not limited to accuracy, legality or non-infringement. HealthTrio is not responsible for the products and services offered by Harvard Pilgrim other than the Service discussed herein.

We cannot always foresee or anticipate technical or other difficulties that may result in failure to obtain data or loss of data, loss of personalization settings, or other service interruptions. We cannot assume responsibility for the timeliness, accuracy, deletion, non-delivery or failure to store any user data, communications, or personalization settings. For example, when displayed through the Service, Account Information is only as fresh as the time shown, which reflects when the information is obtained from such sites. By submitting information to us through the Service, you are allowing us to use that information solely for the purpose of providing the Service. We may use and store the content, but only to provide the Service. By submitting this content to us, you represent that you are entitled to submit it to us for use for this purpose, without any obligation by us to pay any fees or other limitations. 

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When using the Service, information will be transmitted over a medium, which may be beyond the control and jurisdiction of Harvard Pilgrim Health Care, HealthTrio, their customers and/or vendors. Accordingly, Harvard Pilgrim Health Care and HealthTrio assume no liability for or relating to the delay, failure, interruption or corruption of any data or other information transmitted in connection with use of the Service.

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