Below are just a few of the most commonly asked billing questions. If you have any additional questions, please call the Complete Children’s Health billing department at 402-327-6010.

Q: What should I do if I think there is an error with my account or have questions about my bill?

A: Please contact us as soon as possible at 402-327-6010. We must hear from you no later than 60 days after your first bill is sent on which the error problem appeared.

You can telephone us, but doing so will not preserve your rights. In writing, give us the following information: your name, account number, the dollar amount of the suspected error, the posting date of the transaction in question, and an explanation of why you believe there is an error. If you need more information, describe the item you are unsure about. Please be sure the person responsible for the account signs all correspondence.

Q: Does your office participate with my insurance plan?

A: Our office participates with many of the major plans in the Midwest. However it is your responsibility to confirm that your plan covers services that we provide to your child.

Q: Do you submit insurance claims for your patients?

A: Our billing department will make two attempts to obtain payment from your insurance carrier. We submit your claim once you have been seen and then again in 30 days if no payment is made by your insurance carrier. At 60 days if no payment is received by your insurance, we will then bill you and ask that you assist us in following up with your insurance plan.

Q: Will my insurance pay for any of these services: developmental testing, hearing and vision screenings, after hours and weekend charges, immunizations, HPV shots for either boys or girls, asthma services: (aerochambers, peak flow meters, etc.), allergy testing, mental health/behavior diagnosis?

A: There are many different types of insurance policies and they all process claims differently. It is your responsibility to verify with your insurance if they will cover a particular service. If your insurance requires the procedure code and/or price, please contact us.

Q: What is a Co-Pay?

A: A co-pay is a specific amount that you are required to pay at the time of each visit. Complete Children’s Health does require the co-pay to be paid at the time of each visit. Depending on your plan, you may have to pay both coinsurance and a co-pay for a given doctor’s visit. Some carriers do not assess copays for well child visits. If you are sure that yours does not, please inform the front desk at the time of check in.

Q: What is Co-Insurance?

A: This usually means the insurance company pays a certain percentage of our health care bills, while you pay the remaining percentage. In some cases, you may not be expected to pay any coinsurance.

Q: What is a Deductible?

A: Deductible refers to the amount of money you have to pay before your insurance company pays for any health benefits. Once you meet this amount, your insurance benefits go into effect.

Q: Will my newborn be automatically covered under my insurance?

A: Many times newborns are not automatically added to a policy. Insurance companies require that you contact them for enrollment.

Q: What does COB (coordination of benefits) mean?

A: Today, many families are covered by more than one health insurance plan. When two or more health insurance plans cover the insured and dependents, one plan becomes the primary plan and the other plan is the secondary plan. Once a year, most insurance companies will request COB information from the insured to verify whether or not there is any other health insurance. Many times, an insurance company will not process any additional claims until the requested information is received.

Q: How will I be billed for services?

A: Our office sends out statements monthly on any balance that is due from you after your insurance has settled the claim for your child’s services. You are billed for any deductibles, coinsurance or other out of pocket expenses determined by your insurance carrier.

Q: How do I make a payment?

A: Our office accepts payments by cash, check or credit card. You can also pay by phone at 402-327-6010 or on our website through your patient portal.

 

 

FAQ’s regarding commercial health insurance

Q: What is health insurance?

A: Health Insurance is a contract between you and your health insurer to pay some or all of your health care costs in exchange for a premium payment.  For many of our patients, their health plan is offered through their employer or it is purchased through a broker or the marketplace.  Consequently, we DO NOT know the specifics of what your individual insurance policy covers, you should understand the details of the plan you have selected.  If the service is not covered, or you did not provide current information when visiting our office you are responsible for the entire cost of the visit.

Q: What does my insurance pay for?

A: Covered Services (or Covered Charges) are those services provided by a Health Care Provider that are typically allowed under the terms of your contract with your insurance company.  It is important to note that even though services may be allowed, they may not be paid for in full or at all as they may be subject to deductible or co-insurance payments.

Allowed amount is the maximum amount that your insurance company will pay for a health care service provided by your physician’s office.  This may also be called “eligible expense,” “payment allowance” or “negotiated rate.” If your provider charges more than the allowed amount, you may have to pay the difference.

Q: What do I pay for?

A: A health insurance plan generally contains three types of out of pocket payments – copays, coinsurance, and/or deductible.   Each type represents money you have to pay out of pocket for healthcare services you receive.

Copayment (or copay) is a set amount you pay at the time of service (for example, a $25 payment for a doctor visit). Often times a copay is applied for a visit to your primary care provider (PCP) or a specialist.  Copayments are often higher for a specialist than for a PCP.

Coinsurance is your responsibility for a percentage of the cost of the service (for example, 20 percent). Coinsurance is a provision that limits an insurer’s coverage to a certain percentage, commonly 80 percent. This provision is common among most insurance plans and preferred provider plans. If your insurance includes coinsurance, you’ll be responsible for charges beyond those paid by your insurance.

Deductible is a fixed total you are responsible for paying for a period of time (for example $2,500 for the year).  The order in which charges are applied to your deductible versus coinsurance vary greatly by plan design.  Make sure you understand the order in which your plan pays for covered services.

Q: Does my health insurance pay for everything my physician’s office orders?

A: Not necessarily. There may be some services that are routinely provided by your physician’s office that your plans benefit design does not cover.  These are referred to as denied services.  If your insurance denies benefits for a service, you are responsible for the entire cost of the service.

Q: How can I find out what benefits my insurance provides?

A: The best place to start is with the party that provides your insurance to your family.  If your insurance is provided by your employer, check with the HR department or the benefits manager.  If you purchased from a broker, start there.  If you purchased coverage through the marketplace, the government website is a good place to start.  Most insurance cards have a customer service number on the back.  You can also access benefits information through the insurance company’s web site.  Ultimately it is your responsibility to know the details of your benefit plan.

Q: How do I know what my health insurance paid for?

Your health insurance company will provide you an explanation of benefits (EOB) for each claim submitted on your behalf.  It outlines any payment made on your behalf as well as any balances you owe to the physician’s office.  Additionally, it will provide an explanation of any services not covered by your health insurance benefit plan.

Q: What is a provider network?

A: A provider network includes all healthcare providers who have agreed to accept patients covered under a specific health insurance plan.  CCH participates with many major health insurance plans.  Consult your health insurance provider to assure we are in network for your plan.  Often times providers will extend a discount to the insurance company in exchange for the opportunity to have the insurance company’s members as patients. These providers are often referred to as in-network providers or preferred providers.

A narrow network is a much smaller group of providers who have agreed to accept patients covered under a specific health insurance plan.  This smaller group generally provides a greater discount to more exclusively be available to provide services to patients covered under this plan.  It is important to know if you are covered under a narrow network as these plans generally do not pay any benefits if you do not see a contracted healthcare provider.  The cost of those services become the patient’s responsibility.

Q: What is a prior authorization and how does needing one affect my care?

A: A prior authorization is notification required by insurance companies prior to authorizing specific testing or treatment.  Obtaining prior authorization can in some cases delay testing or treatment.  We will generally wait to obtain insurance company approval before proceeding with testing that requires prior authorization.  Sometimes insurance companies deny coverage.  This means that they will not pay for the requested service.  If this occurs, your physician’s office will discuss other options available including possibly other testing or payment out of pocket for the originally recommended service.

Q: What is a Well Child Check and what is included?

A: During a Well Child Check, your Primary Care Provider will monitor your child’s growth and development, give appropriate immunizations, talk to you about important safety issues, and address your general questions and concerns regarding your child.  Your Primary Care Provider also uses the Well Child Check as an opportunity to monitor for early signs of problems so they can be identified and addressed appropriately.  During the Well Child Check, only wellness issues are covered under your wellness benefit.  It is important to be very familiar with the schedule of Well Child Checks that your insurance coverage allows.  This can vary from company to company and could result in unexpected charges.

Q: What if my child is ill on the day of their Well Child Check?

A: If your child wakes up ill on the day of their scheduled Well Child Check and you want the illness to also be addressed or you have other concerns to discuss with your Primary Care Provider on the day of your Child’s Well Child Check, call our office so we can make sure we are able to appropriately address the illness as well as make sure your child gets timely routine well care.  Please know that as your child’s Primary Care Provider, we must follow the rules of your insurance plan and that often includes family payment obligations when combining care for illnesses or other conditions at the time of the Well Child Check.

Q: What is an Evaluation and Management (E&M or sick) visit and what is included?

A: Evaluation & Management (E&M or sick) visits include all other types of office visits that are not Well Child Checks.  For example, your child has a high fever and vomiting, or has pink-eye, or an unusual rash, or an injury sustained on the playground or at a sporting event.  All of these would be considered E&M or sick visits.  They’re generally subject to an out of pocket payment, the type of out of pocket payment is dependent on your insurance plan.

Q: Can I be charged for a Well Child Check and an E&M visit on the same day?

A: There are times when an E&M visit with a Well Child Check are combined. For example, your child may be undergoing their Well Child Check and they also need an asthma or ADHD recheck. Instead of scheduling a second visit, we can provide each visit under the same appointment window.  Or, maybe your child has a mysterious rash that is noticed during their Well Child Check.  Instead of scheduling another appointment, the rash can be evaluated and treated during this time window.  Another example:  your child was injured in a soccer game the evening before their Well Child Check.  We can assess the injury, perhaps order some x-rays and avoid the need for an additional appointment by providing the additional service adjacent to the Well Child Check.  These are a few examples of when a family may be charged for a Well Child Check and an E&M visit on the same day.  This convenience is often appreciated by our families in order to reduce missed school/work and other obligations. Please let us know, however, if your insurance company will not pay for both items on the same day.  We can then schedule separate appointments on separate days if that is necessary.

Q: What is a “formulary” and what should I do if my medication is not covered?

A: A formulary is a list of medications paid for under your health insurance benefits plan.  These can include both name brand and generic medications.  If you find that you have been prescribed a medication that is not on formulary, ask your pharmacist if there is a covered medication that is bioequivalent that is covered.  Often times the brand name medication may not be on formulary but the generic is.

If there is not a bioequivalent that is covered ask your pharmacist to contact CCH and request an updated prescription that is on your formulary.

Q: How am I billed for vaccines?

A: The charge for the vaccine includes the charge for the vaccine product itself plus an additional vaccine administration fee.  This fee is based on the number of components in the vaccine.  Most vaccines have between 1-4 components, although, for example the Pentacel vaccine has five components.    The vaccine administration fee also includes screening for contraindications, educating patients, preparing and administering the vaccine and documenting the vaccines given.   Most routine well child vaccines are covered by insurance with no out of pocket expense.

Our clinic participates in the Vaccines for Children Program.  It is a federally funded, state operated vaccine supply program.  Children birth through 18 years who are uninsured (have no health insurance) or are enrolled in Medicaid are eligible to receive free vaccines that have been supplied to our clinic by this program.  Uninsured patients may be responsible for administration fees.

Q: Why didn’t my insurance pay for my child’s lab tests?

A: Several lab tests can be performed here in our office.  When these tests are done, insurance will process them either applying the test to your deductible and/or coinsurance according to the provisions of your insurance policy or will pay them in full.  The out of pocket cost on these tests is often not included in the office visit copay.

A few of the common tests we perform in our office include:

Urinalysis

Glucose (blood sugar)

Hemoglobin (blood count)

Blood lead

Cholesterol

Strep

Influenza

Covid

RSV

Mono

Many tests are more complex and are not performed in our office. We collect specimens and use an outside lab to perform these tests. Results are reported back to our office to be reviewed with the patient.  A separate lab drawing and handling fee for collecting, preparing, and sending out the specimen occurs when the test is performed by an outside lab.  Some insurance plans specify the outside lab that must be used for your insurance to pay for the tests.  It is your responsibility to know the provisions of your insurance plan and inform our office which lab we can send your test to if it is a test we cannot perform in our office. Some tests are considered experimental or not covered by the insurance plan or are only covered when the patient has a certain diagnosis.  An example of this is vitamin D.  Most insurance companies consider this an experimental test unless the patient has a specific vitamin D deficiency diagnosis that we are treating, not necessarily if we are just screening for a diagnosis.

Q: What are these screens that I am charged for?

A: Developmental Screens: These validated screening tools are used by Physicians and Advanced Practice Providers to monitor cogitative, motor, communication or social-emotional skill development and assist in the early identification of possible delays or risk factors that could interfere with a child’s development.  Results of these screens may lead to further evaluation and diagnosis.

Behavioral Screens: Physicians and Advanced Practice Providers use these screens to monitor children’s mental health and identify those who may be at risk for Anxiety, Depression or ADHD. Additionally, these screens can be used to assist with treatment decisions and monitor response to interventions.  Results of these screens may lead to further evaluation and diagnosis.

Q: What if I have more questions about my health insurance coverage?

A: If your health insurance is provided through an employer, please contact that employer’s HR department or benefits manager.  If you have purchased your insurance through a broker or through the marketplace, please contact the insurance company directly as they can provide the most detailed information regarding plan design and benefits coverage.