Insurance Navigation Tips

Disclaimer:
These are just a few tips we have found helpful in the past.
This is not a legal document.

Key Terms You Should Know:

Co-Pay*: If you have a co-pay on your plan, this is the set fee that you must pay when you use the plan. We will ask you for this payment at the beginning of your child’s visit.

Deductible*: This is the amount that you must pay before the insurance will begin to pay. Many plans will allow you to choose your own deductible, if this is the case keep in mind that the higher the deductible, the lower the premium will be.However, the higher the deductible, the more you will have to pay when you use the plan.

Co-Insurance*: After the deductible there might also be a co-insurance. This means that you and the insurance company will share the cost of your remaining fees. The co-insurance is typically broken down by percentage like 80/20 or 70/30. If you choose a plan that has a 80/20 co-insurance, typically you will be in charge of paying 20% and the insurance will be in charge of the other 80%.

In-Network, Out-of-Network: Medical facilities and practitioners that have contracted with the insurance companies to provide discounted rates, direct billing and other services are considered In Network. Those facilities that have not contracted are considered “Out-of-Network.” The insured will typically save money by using “In-Network” providers and facilities.

Out of Pocket Expense: This is the amount of money that you will pay towards your medical expenses. After your Out of Pocket Maximum is met, your insurance company will pay 100% of all covered charges for the rest of the year (or plan year). Your out of pocket expense is usually in the form of a deductible, co-insurance, copay or some combination of the three.

*Forest Lane Pediatrics offers a convenient way to make payments on your child’s account, called Credit Card on File. At the time of check-in, your credit card can be electronically stored in encrypted form. After the claim for that visit has been processed, your card will be charged for any remaining charges pertaining to that visit. On all subsequent visits, you will be able to use for your card on file for copays and deductibles. You may choose to use your credit card on file or other form of payment for copay. You will be notified by email of pending charges 5 days before the charges occur, and again when the credit card is charged. If you have any questions about the charges you will have 5 days to contact our office before the credit card is charged. (Note: Your copay must be paid at time of visit)

 

Tips To Help Your Visit Go Smoothly:

1. New Insurance? If you have new insurance, call Forest Lane Pediatrics to update your insurance information as soon as possible, especially if your child has an upcoming appointment. This will allow our staff to verify your child’s insurance coverage prior to the appointment and minimize wait time in the office. You will also need to call your insurance company to confirm Coordination of Benefits (see # 3 below).

2. New Baby? In the first month of your baby’s life, he or she will be seeing the doctor to monitor growth and to make sure that he or she is healthy. If your newborn gets sick during the first month of his life, you will be in the doctor’s office even more. It is important to understand your insurance, and to make sure you know how to add your child to your health coverage so that there are no problems with overlapping or non-coverage. Every insurance company is different. Don’t just assume that because you are being covered by an insurance company that they automatically add your child to your plan. Your very first step should be to contact your insurance company to gain a complete understanding of the steps you will have to take. Most often, you will be required to call them within a few days of delivery to add your baby to your plan. Also, check with your human resource administrator to make sure all steps have been taken to add baby to your insurance policy. In most instances, there is a grace period of 30 days to add your baby to the coverage. This is what is referred to as automatic coverage. However, some plans do not offer automatic coverage for your baby, and in most cases, you must add baby to your plan before the automatic coverage window expires in order for any claims to be paid. If you do not add baby to the policy within the required time frame, all of baby’s medical claims will be denied by the insurance company and will be your responsibility.

 

(Now for the really confusing part!)

3. Do Both Parents Carry Insurance Coverage for Your Child? Most health insurance
contracts have a clause that allows the benefits of one policy to be coordinated with the
benefits of other policies. This clause, referred to as Coordination of Benefits (COB), prevents
duplicate payment of health care services. The COB rules follow guidelines established by
the National Association of Health Insurance Commissioners (NAIC).
A. Children covered under more than one plan, with the parents married or living
together:
• The policy of the parent whose birthday (month and day) is earlier in the year
is primary.
• If the parents share the same birthday (month and day), the policy with the
earlier effective date is primary.

B. Children covered under more than one plan, with the parents divorced or living apart:
• The policy of the parent that the court has made responsible for health care
insurance is primary.
• The policy of the parent who has custody of the children is primary.
• If the court has not placed responsibility on one parent to insure the children and the parents have
joint custody, the policy of the parent whose birthday (month and day) is earlier in the year is
primary.
• If the parents share the same birthday (month and day), the policy with the earlier effective date is
primary.
• If you have Tricare and Commercial insurance, the Commercial insurance is always primary.

 

4. What does it mean to “Update the Coordination of Benefits”?  When a staff member at Forest Lane Pediatrics tells you that your child’s claim was denied due to Coordination of Benefits (COB), they will ask you to call your insurance company, update the COB and ask your insurance company to re-file the claim. This means that you need to let your insurance company know that your child is only eligible for one insurance plan, or verify which insurance is the primary insurance BEFORE THEY WILL PAY ANY CLAIMS. Please note, Forest Lane Pediatrics does NOT file claims to secondary insurance, but we are happy to give you a detailed receipt that you can file directly to secondary insurance plans.

 

5. When do you need to call your insurance company to update your child’s Coordination of Benefits?
A. After any request for clarification from your insurance company.
B. At the request of Forest Lane Pediatrics.
C. Any time you switch insurance plans for your child.
We recommend that you ask for a reference number any time you have a conversation with your insurance company! If at all possible, you can also request written confirmation via letter or e-mail.

Still have questions? Call us!
Dallas office (972) 284-7770
Plano office (972) 526-0700