Insurance & Billing

We make every effort to keep down the cost of medical care while maintaining the highest quality of service. As a courtesy to our patients, our offices participate with the insurance companies and managed health care programs listed below. We submit claims once based on information you provide, so please be sure that you keep us informed of any changes to your insurance coverage. For your convenience, cash, personal checks and major credit and debit cards are accepted. For questions regarding insurance participation, or to provide us with updated information about your insurance, please call (410) 451-2116 during our business hours of Monday-Friday, 9am-4pm to speak with a Billing Office representative.

The Pediatric Group uses Alternative Pediatric Services, (APS) to provide courtesy insurance claims filing for patients. APS is required by insurance contracts to follow all of their rules, policies and procedures. Because insurance plans vary widely, are individualized by employer groups, and change from year to year, in many cases you will need to contact your insurance company or employer's benefits department directly for questions regarding coverage. The information below should help you understand the courtesy billing service provided to you by your doctor's office. If, after reading this information, you still have questions, please use the "Contact Us" link for more information.

There are so many different insurance plans that it is not possible for your doctor’s office to know the specific details of each plan. By understanding your insurance coverage, you can know what types of medical care are covered in your plan.

Take time to read your consumer benefits guide, every year. It is better to know what your insurance company will pay for before you receive a service, have tests completed or fill a prescription. Some kinds of care may have to be approved by your insurance company before your doctor can provide them.

If you still have questions about your coverage, call your insurance company and speak with a member services representative for a more detailed explanation.

Remember that your insurance company, not your doctor, makes decisions about what will be paid for and what will not. In addition, your doctor, not your insurance company, decides what medical services you should receive in the interest of your health.

Clinical Care

If you have questions about the clinical services or care you received at a medical practice, please submit your concern directly to the medical facility in writing.

Patient and Account Information

In order to provide you with courtesy billing services and to meet insurance company requirements, the medical practice where you receive care must have accurate insurance and demographic information from you at the time of your visit. It is important to note that you are ultimately responsible for full payment on your account. Some doctor’s offices may also charge a resubmission fee for denied claims based on incorrect information provided at the time of your visit.

Co-Pays and Deductibles

Your health insurance policy is an agreement between you and your insurance company. Insurance companies require subscribers to pay all co-pay and deductible amounts in full at the time of service. Your doctor’s office, according to their insurance contracts, must uphold this rule. If you have questions about your obligations, contact your insurance company prior to your visit.

Resubmissions

We submit claims one time on your behalf, with the information given at the time of your visit, as a courtesy provided to you by your doctor’s office. If a resubmission is required based on new or corrected information you provide, many practices will apply a resubmission surcharge to your account. You are always free to resubmit a claim on your own, but the balance becomes your responsibility to pay if full payment is not received within the time period specified by the physician’s contract with your insurer. In such cases, we suggest that you pursue reimbursement directly from your insurer, or contact your employer's benefits department or plan sponsor for assistance.

Referrals and Prior Authorization

Referrals and prior authorization are required for many types of visits and insurance company requirements vary widely. You are responsible for obtaining the proper referral for your visit. Claims without proper referrals become your responsibility. Please review your plan benefits guide regularly and contact your insurance company for more information or prior to your visit.

Explanation of Benefits

After your appointment, and according to the insurance information you provide, your doctor’s office may submit a bill (also called a claim) on your behalf to your insurance company. A claim lists the services your doctor provided to you. The insurance company uses the information in the claim to pay your doctor for the services you received.

When the insurance company pays your doctor, it might send you a report called an Explanation of Benefits, or EOB, that shows you what it did. You need to be able to read and understand the EOB to know what your insurance company is paying for, what it’s not paying for, and why. An EOB is not a bill.

Your doctor’s office might send you a statement. A statement shows how much your doctor’s office billed your insurance company for the services you received and whether there are any outstanding amounts due for the services that were provided to you. After your insurance company pays your doctor, you may need to pay the doctor any balance due.

Keep in mind that not all insurance companies send EOBs, and not all medical offices send statements. You may receive one or the other or both.

Included below are links to a sample EOB and billing statement with information to help you understand them. You should use what you learn to review your EOBs and billing statements carefully. Here are some things to look for:

• If you have questions about why your insurance company did not cover something or about the amount you have to pay, contact your insurance company.
• If more than 60 days have passed and your insurance company still hasn’t paid your doctor, contact your insurance company. This amount may become your responsibility if your insurance company has not paid within a specified period of time.
• Charges for medical care are determined according to federal rules, insurance contracts and established standards of care. Charges may not be altered or discounted at any time based on a patient’s insurance type or preference. All medical services are provided and billed according to the same guidelines and protocol for all patients.

Finally, you should keep your EOBs and statements organized (e.g., filed by date) so that you can access them easily should questions arise.

All insurers have different rules and distribute different forms of "explanation of benefits" (EOB). These forms can be confusing and differ from insurer to insurer. If you have a question about an EOB you received from an insurer, please consult the insurance company for specific details. We are not able to provide interpretation or analysis of EOBs, or contact insurers on your behalf about your EOB or plan benefits. If you find your insurer is not responsive, we suggest your contact your employer’s benefits department or plan sponsor.

Click here to view a sample EOB.

“Gaps” in Coverage Based on Best Practices