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Insurance

Understanding Your Insurance Plan

We are delighted you have selected Eden Park Pediatrics for your child’s medical care. Our mission is to provide high quality, cost-effective care to the children of our community. To do this, we need your full commitment to our financial policy.

YOUR RESPONSIBILITIES

It is your responsibility to know your insurance benefits.
Your insurance policy is a contract between you and your insurance company, even if your employer provides it. There are many subtle differences in insurance policies, and employers frequently change coverage and co-payments. You are responsible for knowing what services are covered, how often (example - well visits), and how much of the cost is your responsibility.

You are responsible for:

Your copay
Your coinsurance
Your deductible
Any services that your insurance doesn’t cover.

You must provide current, complete, and accurate insurance information at every visit.

This is to protect you from receiving a bill because we did not have correct insurance information. We will attempt to validate your insurance benefits at time of service and alert you to any problems. If we cannot validate your coverage, we may assign your account to self-paid status and request full payment at the end of your visit. Secondary insurance is just as important as primary!

You must present your insurance cards at every visit.
Your insurance card has information you want us to have – like where to send claims, lab work, and who we may refer to. Bring your insurance card to every visit. You should also be aware of where your insurance wants you to go for any lab or radiology procedures, so that in an urgent situation, you are seen at the appropriate facility and will not receive a bill.

You must pay your copay at the time of the office visit.
Our contracts with insurance companies require us to collect your copay at the time of service. We accept cash, credit cards, and checks as forms of payment. If you do not pay your copay at time of service, we will assess a missed copay fee of $20.

If your insurance plan requires you to choose a primary care provider, you must contact your carrier and select one of our doctors before your visit.
In accordance with carrier guidelines, we cannot schedule any appointments or write any referrals until we receive notice that you have been added to our roster.

INSURANCE

If we are participating providers (in-network) with your insurance plan:

We participate with many major insurances. Before scheduling an appointment, please confirm that we are participating providers with yours.
You are responsible to pay at time of service for your copay and any balance not paid by your plan. This balance may be from your coinsurance, your deductible, or any services your insurance did not cover.
If we are participating providers with your insurance plan, all services performed in our office and at the hospital will be submitted to your insurance plan as a courtesy to you.
If there are any problems with this submission, we will notify you and request your prompt assistance with any conditions under your control that are causing a delay in processing (eg. coordination of benefits, wrong insurance ID number, newborn not added to policy). If your insurance carrier does not respond within 30 days, we will contact your insurance for a status update. If your insurance carrier does not respond to our status update request within 60 days from the original date of service, we will send you a statement, and payment will become your responsibility. You will need to contact your insurance carrier if you think they are responsible for payment. Payment from you or them is due within 30 days.

If we are not participating providers (out-of-network) with your plan:

If we do not participate with your insurance plan, payment in full is due at time of service. No exceptions – please do not ask us to bill you.
We will provide you with an itemized bill so you can submit the charges to your insurance for reimbursement.

If we are unable to verify your coverage with your insurance plan:

If we are unable to verify your insurance coverage, all services must be paid for at the time of your visit. No exceptions – please do not ask us to bill you.
Upon receiving verification of coverage, we will bill your insurance company and refund any amounts owed you after your plan has processed the claim.

If you do not have any insurance coverage:

If you do not have any insurance, payment is due at time of service. No exceptions – please do not ask us to bill you.
We provide a courtesy discount of 25% on all services rendered when payment is made at time of service, excluding immunizations.
Immunizations will be provided via the Vaccines for Children program. The allowable rate for administering VFC vaccines (set by the VFC program) will be charged for each vaccine administered.

RESPONSIBLE PARENT

In the case of divorce, please do not place our office into marital disputes. It is your responsibility to work out the payment of your child’s medical care with the other parent.
The adult who accompanies a child to an appointment is responsible for full payment of copays and non-covered services for that day.
Subsequently, bills will be sent to the address of record and the parent who lives at that address will be responsible for payment.

PERSONAL BALANCES

Personal balances are due upon receipt of statement.
If your personal balances is not paid in 30 days, a $20 rebilling fee will be charged.
If your personal balance remains unpaid in 60 days, another $20 rebilling fee will be charged.
If personal balance remains unpaid in 90 days, another $20 rebilling fee will be charged and a final request for payment letter will be issued. Balances not paid in full within 10 days of the date on the final request letter will be forwarded to a collection agency. A 25% charge will be added to the balance to cover the fee charged by the collections agency. Your family will be dismissed from our practice; we will provide urgent care only for your children for 30 days. Upon request, we will provide you with resources to find a new physician.

NEWBORNS

If you have a newborn or newly adopted child, congratulations!

You must contact your insurance carrier immediately after your child’s birth so that your baby is covered under mom’s policy/ID number for the first 30 days.

Be sure to check with us to confirm we are participating providers with mom’s insurance plan.

Permanent coverage must be in place before the 30-day newborn coverage expires.

Your child must have his/her own insurance coverage by the one month well-visit and should have an insurance card to present at that visit. If you have not received an insurance card, contact your insurance company prior to the visit to verify coverage and get an active insurance ID number. If you do not have active coverage your visit may be rescheduled/delayed or you may be personally responsible for the bill.

WELL VISITS WITH ADDITIONAL SERVICES

When your child is seen for preventive care (also known as a well care visit) there may be times when he or she needs an additional service that is not considered preventive. If your child is not well, or a problem is found that needs to be addressed, or you would like to address a problem unrelated to the well visit, the physician will need to provide additional services to care for your child. These additional service are billed to your health plan in addition to the preventive services provided on that day. If you have a copay for office visits, it must be paid at the time of service. Any coinsurances or deductibles must be paid upon receipt of our first billing statement. Some services that may be provided and billed in addition to preventive services include:

The doctor’s work to address more than a minor problem, which will be billed as an office visit (e.g., if the doctor gives a prescription, orders tests, or changes care for a known problem)
Medical treatments (e.g., breathing treatments or wart treatments)
Any surgery (e.g., removing splinters or something the child put in his ear or nose)
Tests performed in the office that are not included in the Bright Futures plan

Our physicians are required to report all services rendered to your health plan based on federal guidelines and the actual services provided. Please feel free to ask questions about services that may not be covered as preventative by your health plan on the day of your visit.

SERVICE FEES

$50 Missed Appointment/Late Cancellation Fee – Missed/Late Cancelled appointments represent a cost to us and to other patients who could have been seen in the time set aside for you. If you need to cancel your well/routine appointment, please contact us at least 24 hours in advance. If you need to cancel your sick/urgent appointment, please contact us at least 2 hours in advance. Recognizing that “life happens” we do not assess a fee for the first missed appointment.* However, a $50 fee will be charged for a second missed appointment. A third missed appointment will result in discharge from the practice. *New patients who miss their first appointment will not be rescheduled.

School/Daycare/Boy Scout Forms - A $5 Form Fee will be charged for the completion of school/daycare/Boy Scout forms. Form will be completed and ready for pickup within 7 – 10 business days. The Form Fee is waived if form is presented at well child visit. If form is needed sooner than 7 – 10 business days, a rush fee will be charged.

PIAA Forms - A $15 Form Fee will be charged for the completion of a PIAA form. Form will be completed and ready for pickup within 7 – 10 business days. The Form Fee is waived if form is presented at well child visit. If form is needed sooner than 7 – 10 business days, a rush fee will be charged.

$30 Returned Check Fee - In the event a personal check is returned unpaid from your bank, your account will be charged with a returned check fee of $30, and your account may be placed on a “cash only” basis until the balance and fee are paid.

$20 Rebilling Fee – A rebilling fee will be charged:

if you do not pay your copay at time of service.
To balances not paid in 30 days
To balances not paid in 60 days
To balances not paid in 90 days

$5 Medical Record Summary Transfer/Copy Fee – A $5 fee is charged to transfer/produce a copy of your child’s medical record including immunizations, problem list, diagnosis history and growth charts.

$25 Evening/Saturday/Holiday Convenience Fee – For your convenience, we offer appointments after the standard 9 – 5 weekday. We charge a $25 convenience fee for this service. Both insurance plans and parents realize that this fee is a cost-effective alternative to a visit to the Emergency Room/Urgent Care and/or taking time off work. This fee is added to all sick visits that are provided:

After 5:00 pm on weekdays
On Saturdays
On Federal Holidays (MLK Day, President’s Day, Columbus Day, etc)

$35 After Hours Fee – If your child needs care when our office is closed, call us. One of our physicians is always on call and will open the office to see your child if it is determined an office visit is advisable. A $35 fee is charged for providing this after hours care.

$100 Reinstatement Fee - Eden Park Pediatrics may, at its discretion, make a one-time exception to reinstate accounts that have been terminated due to missed appointments/delinquent payments.

Coordination of Benefits

WHAT IS COORDINATION OF BENEFITS?

Each year, most insurance companies will ask you to provide them with up-to-date information on any insurance coverage your child may have. If your child is covered by more than one plan, those plans need to work together to make sure you’re getting the most out of your coverage. One plan becomes your primary plan. It pays your claims first. Then the second plan may pay toward the remaining cost, depending on the plan. Coordinating your benefits also maximizes your benefits, which can lower your out-of-pocket costs.

HOW IS PRIMARY AND SECONDARY COVERAGE DETERMINED?

The “Birthday Rule” determines when a plan is primary or secondary for a dependent child when covered by both parents' benefit plan. The parent whose birthday (month and day only) falls first in a calendar year is the parent with the primary coverage for the dependent.

WHY DO I HAVE A PERSONAL BALANCE?

You may have a personal balance because your insurance company sent you a letter requesting that you update your child(ren)’s coordination of benefits (COB) information. To date, your insurance company has not received a reply from you.

WHY IS MY INSURANCE PLAN DENYING MY CLAIMS?

Your insurance plan is rejecting your claim(s) because they need up-to-date information on all insurance coverage your child(ren) may have. Your child may have coverage under only one plan, but your insurance company needs to know that too.

HOW DO I UPDATE MY COORDINATION OF BENEFITS INFORMATION?ow (It’s easy!)

Call your insurance company today at the phone number listed on your insurance card to let them know if your child is covered under any other insurance policies or if they are the only one.
Request that all outstanding claims for your child/children be reprocessed.
Obtain the insurance representative's name and a reference number for your phone call.
Call our billing office at 866-371-6118 x-111 with the name of the representative and the reference number so we can follow up with your insurance company on your behalf for any outstanding claims and remove the balance from your responsibility. If we do not answer, you can leave a voice mail in our secure messaging system.

WHAT HAPPENS IF I DON'T CONTACT MY INSURANCE COMPANY?

You are responsible for this balance until you respond to your insurance company’s request.
Your insurance company may start rejecting all future claims.
You will not be able to schedule well child visits. You will be able to schedule sick visits, but you will be expected to pay for these services in full at time of service.

Thank you for your assistance! We appreciate it!

Insurance Plan List