We have prepared some information to help you better understand what you may expect from your insurance company. As always, please refer to your individual insurance policy for specific coverage guidelines.
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If you have a managed care plan, HMO or POS, you may be required to select a network Primary Care Physician (PCP). If you do not have one of our physicians listed, your insurance will deny your claims and you may be responsible for payment. If you have a PPO plan, you may see any doctor within your network; you do not have to choose one specific doctor. Please refer to your provider directory provided by your insurance company for a complete list of network providers.
If you are referred to a specialist or are seen in an urgent care facility, you are responsible for contacting our office to obtain a referral for your visit. If you require a referral for a specialist, we ask that you schedule your appointment and then contact our office. Please allow at least 3-5 business days for completion of a referral. Not obtaining a referral in a timely manner may result in the need for an appeal letter and/or claim denials. You are ultimately responsible for following procedures for the appeals process outlined by your insurance company.
Newborn babies should be added to your insurance policy within the first 30 days. Please contact your employer for the appropriate paperwork regarding your newborn enrollment. If you do not add your baby to your insurance policy, you may be responsible for denied charges. Do not rely on your employer to follow-up on your baby's eligibility; you should inquire about whether your baby has been added or not.
We require that you present your insurance card at each and every visit. If you have insurance cards for each member of your family, we will need to see the specific child's card at the time of service. We check the card each time to ensure that we have the most up-to-date information in our system. This will aid us in filing your claims timely and accurately.
Many of our patients have experienced changes in the services that their insurance now covers. Some plans now have deductibles and coinsurance, as opposed to just a copay. Some plans may limit the number and/or amount for well child care. We encourage you to review your policy; unfortunately, we cannot be responsible for knowing what your policy does and does not cover. Please review the insurance glossary below to help you better understand some frequently used insurance terminology.
Common Insurance Terminology
COB (Coordination of Benefits)-Information insurance companies request from the patient regarding any other insurance coverage/policies the patient may have.All claims will be pended until the information is received from the patient.Contact your insurance company as soon as you receive this type of request.Coinsurance- A provision stating that the patient and the insurance company will share all services covered by the policy based on a percentage agreed upon in advance (when the policy is written), i.e., 80-20 would mean that the insurance company would pay 80% and the patient would pay 20% of all services.Copayment (Copay)- This is an arrangement where the patient pays a specified amount for various services.The covered person usually must pay his or her copay when the service is rendered.Similar to coinsurance, except that coinsurance is usually a percentage of certain charges where the co-payment is a dollar amount.Deductible- A provision stating that the patient is responsible for a set amount agreed upon in advance (when the policy is written).The patient must meet that set deductive amount before the insurance company will pay any portion of the patient’s claims.Eligibility Date/Effective Date- The date that a patient is eligible for benefits. (EOB) Explanation of Benefits- The statement sent from the insurance company to a patient and/or provider of service listing services, amounts paid by the plan, and total amount billable to the patient.FSA- A flexible spending account, or FSA, is a benefit plan that allows companies to give their workers the opportunity to pay for their out-of-pocket health and dependent care costs on a pre-tax basis, which—over time—lowers payroll-related taxes for both the employer and employees.However, if you don’t use the money you’ve set aside by the end of the year, you lose it.HSA- A health savings account, or HSA, is technically a trust.It’s designed to let you save money specifically for health costs, and receive a tax break in the process.HSA funds not used in one year can roll over to help pay for future expenses the next year.Network- Group of doctors selected and approved to provide services for health plan members; each insurance company has it’s own network of doctors.Primary Care Physician (PCP)-Physician designated by the patientto be responsible for care.Referral- Written or verbal permission for another physician/specialist to see a patient. The patient is ultimately responsible for ensuring the referral is completed prior to being seen by another physician.Specialist- Physician who specializes in a specific area of medicine.Patients are generally referred to specialists by their PCP (That’s us).Timely Filing-Period of time designated by your insurance company in which your medical claim should be filed.By providing the correct insurance information at the time of your visit, you can avoid issues with timely filing.
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