1. The Basics
Insurance coverage is complicated. The same insurance company offers many different types of policies with varying benefits. Benefits should be verified by the policy holder each year on your renewal anniversary because benefits can change from year to year even if you do not change your policy. Benefits can be verified by calling the phone number on the back of your card and following the phone prompts. After you have followed all the automated instructions and prompts, you may have the opportunity to talk to a service representative directly and get your specific questions answered. We recommend you do this. Most PPO insurance plans have “in network” and “out of network” benefits. In network providers (doctors and therapists) give a mandatory discount to your insurance company. At Alliance we have “in network” contracts with Blue Cross and Medicare. If you have Blue Cross or Medicare, we will bill these insurance plans for you. If you have another insurance, your care at Alliance is considered “out of network.” In this case, you will pay Alliance at time of service, and we will give you a receipt that you can send to your insurance company as explained in Item #4 below.
Your deductible (embedded, individual or family) is usually the amount you must spend on services before any insurance benefits are forthcoming. Deductibles usually are met only from the amount your insurance company calculates as a covered amount.
For example, if a covered service is charged at $125 by the provider and your insurance company sets the covered amount for the service at $100, the “in network” provider is required to write off $25.00. If you have a $20 copay with each visit, you will need to pay your provider $100 but only $80 will go toward meeting your deductible. Copays are usually set amounts you pay at each visit. They can be a set amount that is the same for each visit or a percentage of the service charge. Copays can be required even after a patient has met his out-of-pocket limit. A patient can have both a copay of $20 per visit and a co-insurance amount of 20%, 30%, 40% or 50% of the service fee. Co-insurance percentages often exist only until a patient reaches his out of pocket expense limit. Remember each insurance plan is different; you need to verify benefits.
2. The Specifics
Many insurance plans cover medical services (visits to your family doctor or pediatrician) differently from visits with a psychiatrist or mental health therapist. At Alliance Clinical Associates, some of the services rendered may be covered under your medical plan (usually services by an MD). Most others will be covered under your mental health benefits (usually services by our therapists).
a. Benefits for all mental health services may be lower than for primary care services. Occasionally, there is a flat benefit amount per service rendered regardless of the amount of the charge.
b. Mental health benefits may be covered by an entirely different insurance company than the entity that covers your primary care office visits and hospital stays. Your provider may not be contracted with your mental health insurance company.
c. Mental health services often require that visits be authorized by the insurance management company in order for them to be covered. Sometimes an insurance company sets a certain number of allowed visits per year; anything beyond that number will not be covered at all.
d. Hospital benefits for mental health have different parameters than all other medical conditions. Insurance companies often set limits and generally require authorization.
e. Mental health services under some policies only cover services rendered by certain types of providers, eg. only physicians or licensed psychologists. Others do not specify as long as the provider is licensed.
f. Most PPO policies will cover “out of network” providers at a lower rate; others, including most HMO’s, may not cover any “out of network” providers at all.
g. Prescription benefits vary with each policy. If you have prescription benefits, medications on the insurance policy formulary may be covered at higher rates than those not on the formulary list. Some medications will be less expensive if they are mail ordered. Some medications need pre-authorization before your pharmacist will fill them.
h. Coverage for mental health services is sometimes dependent on the diagnosis. Some policies only cover a “serious” diagnosis; other policies cover all diagnoses but pay differently for the “not serious” diagnosis.
3. Special Note
While your insurance company will say that all verifications are NOT a guarantee of coverage, getting them to explain the issues above will be helpful in understanding your coverage and your projected out of pocket cost of treatment so you can make informed decisions.
4. How to file your own insurance claim
If we are not contracted with your insurance company, you can file claims for reimbursement yourself. Each time you see a therapist, you will receive a “superbill” upon checkout. The superbill contains the service code, diagnosis, provider information and the fee charged. All you need to do is provide your insurance ID and Group #. Generally, you then receive the reimbursement check. If your insurance company sends us a check after you have paid for a date of service, we will issue you a refund check.
Some insurance companies require a special claim form to be filled out by you. If so, the superbill will provide you with all the information you need to fill in their form. Usually the forms are available from their website or you can call and request them to mail you a form.
ALLIANCE CLINICAL ASSOCIATES
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