Insurance Plans

We will file insurance under the following plans:

  • AETNA PPO, HMO, POS ** MUST BE PCP FOR HMO/POS **
  • BLUE CHOICE HMO,POS,FED EMP POS PLAN, PPO, INDEMNITY ** MUST BE PCP**
  • CIGNA HMO, POS, PPO ( NOT THE INDEMNITY PLAN) **PCP**
  • COVENTRY HEALTHCARE HMO, POS  ** MUST BE PCP**
  • COVENTRY/SOUTHCARE/FIRST HEALTH PPO
  • GREAT WEST/CIGNA PPO
  • HUMANA HMO,POS, PPO/CHOICE CARE (MUST BE THE PCP FOR HMO/POS)
  • KAISER ADDED CHOICE (PHCS ONLY)
  • MULTIPLAN /PREFERRED PLAN OF GA (NOT PROAMERICA!)
  • PRINCIPAL HEALTHCARE (PHCS or SOUTHCARE network)
  • UNITED HEALTHCARE
  • USA HEALTH NETWORK PPO

WE DO NOT ACCEPT BEECH STREET or PPO Next (term 9/30/07)

WE DO NOT FILE CLAIMS FOR INTERNATIONAL PLANS (AS OF 9/1/2018)

WE DO NOT GENERALLY FILE CLAIMS FOR MED SHARE TYPE PLANS AS THESE ARE NOT INSURANCE PLANS. PLEASE CALL OUR OFFICE TO CONFIRM IF WE CAN FILE YOUR PLAN AS A COURTESY.

WE DO NOT FILE FOR FREEDOM LIFE

COVENTRY HEALTH PLANS IS THE UMBRELLA COMPANY THAT OWNS

  • Coventry HMO
  • First Health PPO
  • SouthCare PPO
  • Coventry National PPO
  • Fortis

10 Things to Know About Your Insurance Coverage

  1. After your new baby arrives you must notify your employer and your insurance company to add her/him to the policy. The insurance company DOES NOT automatically know this just because they received a claim for the birth. The baby is PRESUMED covered under the mother’s policy for 30 days, but this is pending the baby being added to the plan.
  2. Some Point of Service (POS) and all Health Maintenance Organization (HMO) plans require you to choose a Primary Care Physician (PCP). One of our doctors MUST be listed on the card in order for your insurance company to pay the claim!
  3. PLEASE bring YOUR CHILD’S insurance card to EVERY visit! Often your child’s card will have a different number or suffix and it doesn’t always go sequentially (for example, the subscriber may be 01, spouse 03, and child 07). Even if you keep the same insurance company from one year to the next it is likely that some information has changed like the claims address or network, your benefits, amount of copay, deductible, coinsurance, and out of pocket expenses.
  4. We DO NOT know the specifics of what your specific insurance policy covers and you should understand the details of the plan you have selected. There could be numerous benefits and cost variations your employer has chosen. There are literally dozens of different plans from BCBS, United, Aetna, Cigna, and other smaller insurance networks.
  5. Most insurance policies now have a deductible and/or coinsurance, which may be in addition to your copay.
  6. In general, most policies now cover preventive health visits (check-ups) without a copay, coinsurance, or deductible. However, this does not mean that all services done at the health check are covered. Many insurance companies do not fully cover charges for additional services like hearing/vision screen and hemoglobin/cholesterol testing.
  7. If you want the physician to address any other significant concerns during the health check (like an ear infection, asthma, or ADHD), this will likely NOT be included as part of the health check. This means your insurance company will require you to cover the cost via copay, coinsurance, or deductible.
  8. Our doctors recommend treatments or services that they feel are best for your child: a service (like lactation consultation, a lab test or vision screen), a treatment (ear wax removal), a prescription or referral to a specialist. This unfortunately doesn’t mean that your policy will cover these services. In order to avoid significant out of pocket costs, you should check to see if that service or physician is covered “in network” BEFORE you have the service. Most insurance companies will not go back and reconsider a charge if there was another option.
  9. Your insurance policy is a contract between you and the insurance company. As a courtesy, we will file the claim one time initially with the insurance information you provide at the visit. If the service is not covered, or you did not provide the current information, we are not responsible for refiling the claim and you may be responsible for the entire cost of the visit.
  10. We want to provide the best care we can in the most cost efficient manner to help you get the most from your insurance benefits. Please work with us by providing timely and accurate information. If you know there is going to be an issue please let us know up front so we can work with you.

Useful Terms and Symbols

Coinsurance: The money you have to pay for health services after you have paid the deductible

Copayments: The fee paid for a doctor visit, hospital stay or other service

Deductible: The amount of money you pay before your insurance starts to pay

Eligible expense: A service or product recognized by the IRS that is purchased to help treat a medical condition or prevent a disease

Employee contribution: The money an employee pays to be covered by a health plan; also called “premium”

Flexible Spending Account (FSA): An employer sponsored account in which pre-tax funds are set aside from an employee’s paycheck each year. FSA funds can be used for eligible medical expenses, dependent care or commuter expenses, as determined by the IRS

Health Maintenance Organization (HMO): A kind of health insurance plan that usually requires members to receive services through doctors, labs, and hospitals that contract or work with the HMO

Health Reimbursement Account (HRA): Health care accounts that employers fund for covered workers or retired persons; IRS does not tax this money; also call Health Reimbursement Arrangements

Health Savings Account (HSA): Health care bank accounts that let people put money aside tax free to pay for medical, dental and vision costs; IRS limits who can open and put money into HSA; money in HSA stays in the account until it is used

Network provider: All the doctors, hospitals, nursing homes and laboratories that have contracts with an insurance company; also called “in-network” provider and “participating network” provider

Non-network provider: Doctors, hospitals, and other health care professionals who do not participate in our network and may provide services at a higher cost

Out-of-pocket maximum: The most you have to pay for health services; once paid, the insurance company pays 100 percent of eligible health care costs

Point-of-service (POS): A health benefit plan that allows the covered person to choose to receive service from a participating or non-participating physician or other health care provider, with different benefit levels associated with the use of participating physicians or other health care providers

Preferred Provider Organization (PPO): An organization where providers are under contract to provide care at a discounted or negotiated rate.