Appointments: (631) 732-5222

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Insurance & Billing FAQ

Browse F.A.Q. Topics

Deductables & Copays

  • Why did I get a bill, I have insurance?
    There are many reasons this might occur, including:
    • Your insurance company denied the claim
    • You have not yet met your deductible
    • Your insurance company has not yet received a copy of your claim (usually due to either incomplete or incorrect information)
    • Your insurance information with us is not up-to-date, and your old insurance was billed
    • Your insurance has processed the claim but requires a higher co-pay than what was provided at the time of service
    • We have received a response from your primary insurance and are in the process of billing your secondary insurance.
    • Your insurance company may limit the number of well care visits to an amount that is lower than recommended by American Academy of Pediatrics guidelines.
  • When are deductibles due?
    Deductibles are due at the time of service. We will do our best to estimate your deductible balance after your visit with the doctor. After your insurance company processes the claim, we will make any necessary adjustments, and inform you of any differences.
  • What is a Deductible?
    A deductible is defined by a clause in your insurance contract. It requires you to pay for an initial, specified amount of service before your insurance company begins to pay for services. Once your deductible is met, your insurance company will pay claims as defined by your plans provisions.
  • When is My Co-Pay Due?
    Your co-pay is due at the time of service, prior to seeing the doctor. If the co-pay amount is unknown, we will ask for the anticipated amount then either bill you later if underestimated or credit your account if overestimated. At visits where laboratory co-pays are involved, they will be collected after your child sees the doctor. The exception to this is if your reason for visit obviously requires testing (ie: “I want my child checked for strep”).

General

  • What if my pharmacy tells me that they can’t fill my prescription because it not covered by my insurance carrier?
    There are many prescription medicines that require prior authorization before your pharmacist can fill the prescriptions. If your prescription is denied, please call us, and we will attempt to acquire approval from your insurance carrier. With many insurance carriers, there are some medications that will not be covered under any circumstances. When this occurs, please discuss possible alternatives with your doctor.
  • What if I need a referral to see a specialist?
    The doctor may refer your child(ren) to see a specialist. Some insurance carriers require a pre-written referral authorized by your insurance carrier for these visits. We will gladly acquire that for you, however, it is your responsibility to know if one is required. It is impossible in most cases to acquire the referral after the visit with the specialist. Without the referral authorization, you will incur fee for service charges from the specialist’s office for your visit.  With many insurance companies it requires 24-48 hours to approve referrals.  Please allow at least this amount of time when requesting a referral.
  • Your website says you accept my insurance plan, but when I called to change my Primary Care Physician (PCP) they said you were not participating?
    This can be due to several issues:
    • Your insurance company has made an error. For example, one company accidentally listed us as Allergists and has since corrected their error.
    • Your insurance company has several plans within it and we only accept some of them.
    • We have decided no longer to participate with the plan, but neglected to update the website to reflect the change.
    Regardless of the ultimate reason, if you are having any issues regarding whether or not we accept your insurance plan, please call us. We will be happy to clarify the issue with you.
  • What if I disagree with how my insurance processed my claim?
    Try checking your member benefits manual to ensure your concern is valid. If you still have concerns, call the Member Services number which is usually located on your insurance card. If you require any assistance from us to support your appeal, please contact our billing department.
  • How do I know what services are covered under my insurance plan?
    Your member benefit manual will usually discuss these issues. If not, or you have further questions, please call your insurance company. If you require any codes to help them assess your situation, please call our billing department and we will attempt to help clarify your situation.
  • Do you take my insurance?
    Our current list of accepted plans can be found here. If you do not see your plan listed, call our billing department and we will inquire as to what it takes to join their panel of doctors.
  • I have no insurance, will you treat my child?
    Yes we will.
  • Can you alter the way my child’s visit is billed to ensure my insurance will pay the claim?
    Unfortunately, we cannot. We must bill for what we do according to strict guidelines. Anything else is considered fraudulent.
  • What if my insurance denies a service as being inclusive?
    This occurs when your insurance company deems a service or test rendered as part of another service rendered on the claim. We will work through the insurance companies appeal process in these cases. If, after exhausting all appeals, the service is still denied, the patient will be held responsible for any charges associated with the service rendered.
  • What if my insurance denies a service as “not covered”?
    We will do our best to advise you if a recommended test or service is not covered by your insurance before proceeding. We do not perform tests or services in the office “just because we can,” so before seeing the doctor it is a good idea to check with your insurance company to see which tests and services are covered under your policy. Tests and services not covered by your insurance will be considered your responsibility.
  • How do I know when my insurance has responded to a claim?
    You will receive an Explanation of Benefits (EOB) form when your claim is processed. This form will explain what was charged, what was paid by the insurance company, and what portion is the patient’s responsibility. You will usually receive the EOB before we receive payment, and this may result in a discrepancy in what we have listed as your current balance with what you expect it should be.
  • What if my newborn’s claims are denied?
    This is usually due to a lag in the insurance company updating their records. Please call your insurance to confirm that your newborn was added to your policy. When you speak with your insurance company, ask the representative to reprocess all denied claims on file and then advise our billing department that you have done so.  We can then follow up with the insurance company to verify claims are being paid.
  • How do I add my newborn to my policy?
    In most cases, insurance companies allow 30 days for you to add your newborn to your policy. Contact your insurance provider or your Human Resource Department to obtain and complete the required paperwork to add your newborn to the policy.
  • Can you bill my ex-spouse for the visit?
    We understand that in many cases a court has obligated one spouse to cover all medical bills. Unfortunately, we will hold the person bringing the child to the office responsible for any bills as they are the ones who sign our financial agreement. It is then their responsibility to ensure that any court ordered financial agreements are carried out.
  • Did you receive my payment?
    You can check this multiple ways:
    • Follow your checking/credit card balances to assess if payment was rendered
    • Check your login account (Patient Portal)
    • Call our Billing Department at 631-732-5222
  • Why do I have to present my insurance card at each visit?
    This policy especially applies to Medicaid, for which eligibility is determined on a month-to-month basis. This policy is mainly for your protection. If your insurance denies your claim for eligibility reasons, we have a copy of your card with which to begin working with the company to process the claim.
  • Why did I get a bill, I have insurance?
    There are many reasons this might occur, including:
    • Your insurance company denied the claim
    • You have not yet met your deductible
    • Your insurance company has not yet received a copy of your claim (usually due to either incomplete or incorrect information)
    • Your insurance information with us is not up-to-date, and your old insurance was billed
    • Your insurance has processed the claim but requires a higher co-pay than what was provided at the time of service
    • We have received a response from your primary insurance and are in the process of billing your secondary insurance.
    • Your insurance company may limit the number of well care visits to an amount that is lower than recommended by American Academy of Pediatrics guidelines.
  • When are deductibles due?
    Deductibles are due at the time of service. We will do our best to estimate your deductible balance after your visit with the doctor. After your insurance company processes the claim, we will make any necessary adjustments, and inform you of any differences.
  • What is a Deductible?
    A deductible is defined by a clause in your insurance contract. It requires you to pay for an initial, specified amount of service before your insurance company begins to pay for services. Once your deductible is met, your insurance company will pay claims as defined by your plans provisions.
  • When is My Co-Pay Due?
    Your co-pay is due at the time of service, prior to seeing the doctor. If the co-pay amount is unknown, we will ask for the anticipated amount then either bill you later if underestimated or credit your account if overestimated. At visits where laboratory co-pays are involved, they will be collected after your child sees the doctor. The exception to this is if your reason for visit obviously requires testing (ie: “I want my child checked for strep”).
  • What Is A Co-Pay?
    A co-pay is a specific dollar amount that is an out-of-pocket expense as per the contract with your insurance company. The co-pay amount is usually stated somewhere on your insurance card. Some insurance companies have different levels of co-pay depending on services rendered. For example, a sick visit might carry a co-pay of $20, while a sick visit requiring lab testing (ie: strep test, flu swab) may have a co-pay of $30.

Insurance Coverage

  • What if my pharmacy tells me that they can’t fill my prescription because it not covered by my insurance carrier?
    There are many prescription medicines that require prior authorization before your pharmacist can fill the prescriptions. If your prescription is denied, please call us, and we will attempt to acquire approval from your insurance carrier. With many insurance carriers, there are some medications that will not be covered under any circumstances. When this occurs, please discuss possible alternatives with your doctor.
  • What if I need a referral to see a specialist?
    The doctor may refer your child(ren) to see a specialist. Some insurance carriers require a pre-written referral authorized by your insurance carrier for these visits. We will gladly acquire that for you, however, it is your responsibility to know if one is required. It is impossible in most cases to acquire the referral after the visit with the specialist. Without the referral authorization, you will incur fee for service charges from the specialist’s office for your visit.  With many insurance companies it requires 24-48 hours to approve referrals.  Please allow at least this amount of time when requesting a referral.
  • Your website says you accept my insurance plan, but when I called to change my Primary Care Physician (PCP) they said you were not participating?
    This can be due to several issues:
    • Your insurance company has made an error. For example, one company accidentally listed us as Allergists and has since corrected their error.
    • Your insurance company has several plans within it and we only accept some of them.
    • We have decided no longer to participate with the plan, but neglected to update the website to reflect the change.
    Regardless of the ultimate reason, if you are having any issues regarding whether or not we accept your insurance plan, please call us. We will be happy to clarify the issue with you.
  • What if I disagree with how my insurance processed my claim?
    Try checking your member benefits manual to ensure your concern is valid. If you still have concerns, call the Member Services number which is usually located on your insurance card. If you require any assistance from us to support your appeal, please contact our billing department.
  • How do I know what services are covered under my insurance plan?
    Your member benefit manual will usually discuss these issues. If not, or you have further questions, please call your insurance company. If you require any codes to help them assess your situation, please call our billing department and we will attempt to help clarify your situation.
  • Do you take my insurance?
    Our current list of accepted plans can be found here. If you do not see your plan listed, call our billing department and we will inquire as to what it takes to join their panel of doctors.
  • I have no insurance, will you treat my child?
    Yes we will.
  • Can you alter the way my child’s visit is billed to ensure my insurance will pay the claim?
    Unfortunately, we cannot. We must bill for what we do according to strict guidelines. Anything else is considered fraudulent.
  • What if my insurance denies a service as being inclusive?
    This occurs when your insurance company deems a service or test rendered as part of another service rendered on the claim. We will work through the insurance companies appeal process in these cases. If, after exhausting all appeals, the service is still denied, the patient will be held responsible for any charges associated with the service rendered.
  • What if my insurance denies a service as “not covered”?
    We will do our best to advise you if a recommended test or service is not covered by your insurance before proceeding. We do not perform tests or services in the office “just because we can,” so before seeing the doctor it is a good idea to check with your insurance company to see which tests and services are covered under your policy. Tests and services not covered by your insurance will be considered your responsibility.
  • How do I know when my insurance has responded to a claim?
    You will receive an Explanation of Benefits (EOB) form when your claim is processed. This form will explain what was charged, what was paid by the insurance company, and what portion is the patient’s responsibility. You will usually receive the EOB before we receive payment, and this may result in a discrepancy in what we have listed as your current balance with what you expect it should be.
  • What if my newborn’s claims are denied?
    This is usually due to a lag in the insurance company updating their records. Please call your insurance to confirm that your newborn was added to your policy. When you speak with your insurance company, ask the representative to reprocess all denied claims on file and then advise our billing department that you have done so.  We can then follow up with the insurance company to verify claims are being paid.
  • How do I add my newborn to my policy?
    In most cases, insurance companies allow 30 days for you to add your newborn to your policy. Contact your insurance provider or your Human Resource Department to obtain and complete the required paperwork to add your newborn to the policy.
  • Can you bill my ex-spouse for the visit?
    We understand that in many cases a court has obligated one spouse to cover all medical bills. Unfortunately, we will hold the person bringing the child to the office responsible for any bills as they are the ones who sign our financial agreement. It is then their responsibility to ensure that any court ordered financial agreements are carried out.
  • Why do I have to present my insurance card at each visit?
    This policy especially applies to Medicaid, for which eligibility is determined on a month-to-month basis. This policy is mainly for your protection. If your insurance denies your claim for eligibility reasons, we have a copy of your card with which to begin working with the company to process the claim.
  • Why did I get a bill, I have insurance?
    There are many reasons this might occur, including:
    • Your insurance company denied the claim
    • You have not yet met your deductible
    • Your insurance company has not yet received a copy of your claim (usually due to either incomplete or incorrect information)
    • Your insurance information with us is not up-to-date, and your old insurance was billed
    • Your insurance has processed the claim but requires a higher co-pay than what was provided at the time of service
    • We have received a response from your primary insurance and are in the process of billing your secondary insurance.
    • Your insurance company may limit the number of well care visits to an amount that is lower than recommended by American Academy of Pediatrics guidelines.
  • When are deductibles due?
    Deductibles are due at the time of service. We will do our best to estimate your deductible balance after your visit with the doctor. After your insurance company processes the claim, we will make any necessary adjustments, and inform you of any differences.

Newborn added to policy

  • What if my newborn’s claims are denied?
    This is usually due to a lag in the insurance company updating their records. Please call your insurance to confirm that your newborn was added to your policy. When you speak with your insurance company, ask the representative to reprocess all denied claims on file and then advise our billing department that you have done so.  We can then follow up with the insurance company to verify claims are being paid.
  • How do I add my newborn to my policy?
    In most cases, insurance companies allow 30 days for you to add your newborn to your policy. Contact your insurance provider or your Human Resource Department to obtain and complete the required paperwork to add your newborn to the policy.

Payments/Bills

  • Can you alter the way my child’s visit is billed to ensure my insurance will pay the claim?
    Unfortunately, we cannot. We must bill for what we do according to strict guidelines. Anything else is considered fraudulent.
  • Can you bill my ex-spouse for the visit?
    We understand that in many cases a court has obligated one spouse to cover all medical bills. Unfortunately, we will hold the person bringing the child to the office responsible for any bills as they are the ones who sign our financial agreement. It is then their responsibility to ensure that any court ordered financial agreements are carried out.
  • Did you receive my payment?
    You can check this multiple ways:
    • Follow your checking/credit card balances to assess if payment was rendered
    • Check your login account (Patient Portal)
    • Call our Billing Department at 631-732-5222
  • Why did I get a bill, I have insurance?
    There are many reasons this might occur, including:
    • Your insurance company denied the claim
    • You have not yet met your deductible
    • Your insurance company has not yet received a copy of your claim (usually due to either incomplete or incorrect information)
    • Your insurance information with us is not up-to-date, and your old insurance was billed
    • Your insurance has processed the claim but requires a higher co-pay than what was provided at the time of service
    • We have received a response from your primary insurance and are in the process of billing your secondary insurance.
    • Your insurance company may limit the number of well care visits to an amount that is lower than recommended by American Academy of Pediatrics guidelines.

© Peds First Pediatrics    2799 Route 112, Suite 11, Medford, NY 11763    631-732-5222