Introduction:

We know that there are many questions when it comes to dealing with insurance companies regarding referrals and bills from physicians’ offices. Below we have listed answers to the most common questions asked by our parents. We hope that this will help. If you need further assistance or your question has not been addressed here, please contact our bookkeeper Shelley at 206-783-7042 during regular office hours.
 

Billing and Insurance Frequently Asked Questions:

Q: Why do I get a separate bill for each child?

A: Each child in your family has a unique account number on our computer system. However, you should only receive one statement per month. If you are receiving multiple statements please contact our business office at 206-783-7042.
 

Q: I received a statement for services that should have been covered in full by my insurance company. Why is that?

A: If you receive a statement from us and there is a balance that should have been covered by your insurance company we ask that you call your insurance company to find out why the claim was not processed correctly. Please remember that you are going to get an EOB (Explanation of Benefits) from your insurance company showing how a claim was processed. Please review these each time, as the insurance company will give an explanation for charges that they consider patient responsibility.
 

Q: I received a statement from you showing that my insurance company has not been billed. Why is that?

A: There are a couple of reasons why you would receive a statement from us showing that you are responsible for charges for a visit. Usually it is because we have not yet received your insurance information, or because we have billed your insurance several times with no response. We will typically put a note on your statement letting you know what we need in order to file the claim through the insurance. There are times that we just need the parents’ help with getting the insurance company to process the claim.
 

Q: I brought my child in for a well-child visit and payment was denied by my insurance company as “Maximum benefits have been expended for this service.” Why was that?

A: Insurance companies differ in how many well-child exams will be covered in the first year of your baby’s life. It is best to look at your benefit booklet or call your insurance company. Please keep in mind that insurance companies will only cover one exam per year after the child’s first birthday. When you call to schedule the exam, please ask the receptionist when the last visit was. We have seen insurance companies deny the claim if the visit occurred one day shy of a year.
 

Q: If both parents have insurance coverage for their child, which one would be primary?

A: All insurance companies follow the birthday rule. The parent whose birthday is first in the calendar year will be considered “primary” for insurance purposes.
 

Q: Will you bill both of my insurance companies?

A: At this time we are only billing the primary insurance. If you are planning to submit a claim to a secondary or supplemental insurance, please ask your physician for a copy of your bill at the time of your visit. Once your primary insurance company has sent you the EOB (Explanation of Benefits) you will want to attach it to the copy of our bill and send it to your secondary insurance.
 

Q: When and why do I need a referral to see another physician?

A: If your child is covered under a managed care plan then anytime you seek medical care from another physician you will need to get a referral from your PCP (“primary-care physician”). If you need to have a referral please contact Sandy at 206-783-9300 and she can assist you with it. Please keep in mind that we need to have at least 5-7 days notice to get the referral processed through your insurance company.
 

Q: How do I know if your physicians are covered under my insurance plan?

A: We always recommend that you contact your insurance company to see if we are contracted provider. We are contracted with a large number of insurance companies, so there should not be a problem. However, there are times that we may not renew a contract so relying on the physician booklet may not be a good idea, as these books are only published once a year and may not be accurate.

Referral Frequently Asked Questions:

Q: Will insurance companies do retroactive referrals if I see a specialist and forget to request a referral beforehand?

A: Most insurance plans will honor retroactive referral requests for 7 days past the date of service.If it has been longer than 7 days some companies will require chart notes from your physician so they can review to see if the intent to refer was there; however some will not allow retroactive referrals at all. It’s always a good idea to call our office to be sure the referral is in place before the appointment with the specialist.
 

Q: What if my physician recommends a specialist that is not in my insurance network?

A: A few insurance plans have out of network benefits which will allow you to see a specialist even if that physician is not contracted with the plan; however the claims will be paid at a lower benefit rate than if you stayed within network. In most cases your physician would try to re-direct your child to a specialist who is contracted, since most plans do not pay at all if you go out of network.
 

Q: What should I do if my physician refers my child to a clinic at Children’s Hospital?

A: If your child will be a new patient to that clinic then our office will first send a New Appointment Request Form (NARF) to a processing center at Children’s Hospital. The NARF will provide the Children’s clinic with medical information on why the child needs to be seen and a phone number to reach you. The clinic scheduler should make contact with you within 3-5 days to set up an appointment time. After the appointment is made Children’s will contact our office with the specialist’s name and the date of the appointment so that a referral can be made if your child is covered under a managed care plan. It is a good idea for the parent to follow up with our office to be sure the referral has been done.
 

Q: Is a referral necessary for After Hours Clinic visits at Children’s Hospital?

A: We need to do a referral for those patients covered under a managed care plan. The hospital usually requests the referral from us after the visit, but we recommend that you follow up with a phone call the next business day to be sure we have been notified.
 

Q: What if my physician recommends speech, physical or occupational therapy services for my child?

A: You should first check with your insurance company to see what therapy services are covered by your plan. Some plans do not provide these services. If the benefits are included on your plan your physician will send a prescription to the therapist that will be used when the therapist bills the insurance. As with referrals to specialists, most plans will require that you stay within network.
 

Q: What if my physician recommends a mental or behavioral health referral for my child?

A: Many companies have arranged for other organizations to manage their mental health benefits. You should look on your insurance card for a phone number or call the insurance company for information. Usually you will be advised to call the behavioral health service directly to initiate the referral instead of contacting our office for a referral.