Billing & Insurance FAQs
ABOUT FRACTURE AND SURGERY CHARGES
CPT Codes
Physicians bill using CPT codes. Physicians are REQUIRED to bill according to the CPT guidelines divided into categories:
• Evaluation and Management which covers office, ER or inpatient exams, histories, review of imaging and outside notes.
• GLOBAL Codes which include treatment of fractures, surgery, injections and other office procedures. This is a bundle package good for 10-90 days of visits. Follow up visits are free within this time. Fractures and Surgeries are global CPT codes. THESE CODES GO TO YOUR DEDUCTIBLE. Included in this package is: treatment of fracture or surgery, 90 days of office follow up visits and the first application of splint or cast.
INSURANCE COMPANIES LIST ALL GLOBAL CODES AS “SURGERY” EVEN IF THE CODE IS FOR A NON-DISPLACED FRACTURE IN THE OFFICE SETTING, AND NOTHING CLOSE TO SURGERY OCCURS.
NOT INCLUDED IN THE GLOBAL PACKAGE:
• Subsequent cast changes – slings – splints – braces- cast supplies
• X-rays
• Treatment not related to the original fracture or surgery
The contracted fee is the “Allowable fee” that you and your insurance company are responsible for.
We hope this helps you understand your EOB (Explanation of Benefits) from your insurance company and our bill based on the EOB from your insurance company.
If you have questions, call your insurance company, and/or our billing company at (520) 529-5526. We outsource our billing.
Deductible
The deductible is the amount you pay before insurance pays. Deductibles restart January 1st. Some plans pay doctor visits without meeting the deductible first.
Co-insurance
One common co-insurance split is 80/20. The insurance company will pay 80%, and you pay 20%. After the deductible is met, you are responsible for 20% of the bill.
Co-payments
The co-payment is amount due at time of service. We charge the amount our eligibility software shows us. It may be wrong, in which case we will bill you the difference or refund you.
CONTRACTED INSURANCE COMPANIES
Effective January 1st, 2012 our office requires courtesy referrals for ALL insurances policies.
COURTESY REFERRALS APPRECIATED FOR ALL PATIENTS
ACPN ( America’s Choice Provider Network)
AETNA
Ambetter
Arizona Complete Healthcare (AHCCCS)
ARIZONA FOUNDATION (See Third Party Payors below)
BANNER HEALTH (In-Network)
Banner UNIVERSITY FAMILY CARE ( AHCCCS) (Requires referral from PCP)
BLUE CROSS BLUE SHIELDwithCERTAIN GROUP NUMBERS (See Third Party Payors on page 2)
CIGNA (HMO plans require referral from PCP) (See Third Party Payors on page 2)
EQUALITY HEALTH NETWORK
FIRST HEALTH/COVENTRY/CNN
FORTIFIED PROVIDER NETWORK
Fusion Network
GEHA
GOLDEN RULE
GREATWEST
Steward/Health Choice ( AHCCCS) (requires referral from PCP)
HUMANA (HMO plans require referral from PCP)
Indian Health Services with AHCCCS (Requires dated referral from IHS)
Liberty Healthshare
MARKETPLACE PLANS (Healthnet AMBETTER)
Medi-Share (we accept, but are considered “out of network”)
Mercy Care (AHCCCS and Foster)
TRICARE (Prime plan requires prior authorization from PCM)
UNITED HEALTH CARE – all plans including Community Care (AHCCCS)
All Savers through UHC Choice Plus
UNITED MEDICAL RESOURCES (UMR)
Banner UNIVERSITY FAMILY CARE ( AHCCCS) (Requires referral from PCP)
We do accept “out of network” authorizations for private companies we are not contracted with. Please call our office to obtain CPT codes patient will need for you to obtain the auth. Also, we accept self-pay patients. All non-contracted patients will be required to pay in full at time of appointment, and we will courtesy bill for them and refund the deposit.
ARIZONA FOUNDATION Third Party Payors including:
ACS / The New England
Administrative Service Consultant
Advanced Benefit Solutions
Allied Benefit Systems
Altpros, Inc.
Ameriben Solutions / IEC Group
American Community Mutual Insurance Co.
American National Insurance
Assurant Health
Avidity
Auxiant (formerly Professional Claim Administrators)
Benefit Administrative Systems
Benefit Planners, Inc.
Benefit Systems & Services, Inc.
Best Life Assurance Company
Brokerage Concepts and/or Brokerage Services
Business Administrators & Consultants
Canadian Medical Network / Care Mgmt Network
CBCA Administrators
CDS Administrators
Central Reserve Life / Ceres
Claims & Benefits, Inc (Refer to Noridian Benefit Plan Administrators)
CNIC Health Solutions
Continental General Ins / CERES
Coresource-Minnesota (previously Core Star)
Corp Benefit Svcs of America / Meritain Health
Coventry Health Care (previously Mutual of Omaha)
Aberdeen Health Care Service Center
Charlotte Health Care Service Center
Woodward Healthcare Service Center
Cypress Benefit Administrators
Delta Health Systems
ECOM PPO Advisors, Inc
Edward C. Levy (CoreSource)
Employee Benefit Management Services
Epoch Group, The
Erin Group Administrators
First Administrators / Ecom PPO
FMH Benefit Services, Inc.
Fox-Everett
Freedom Life Insurance Company of America
Fringe Benefit Services
GEHA
Gilsbar, Inc.
Global Excel Management, Inc.
GMS, Inc.
Group Resources Incorporated
UMR (formerly Harrington Benefits / Fiserv)
HCH Administration
HDM Benefit Solutions
Healthcare Group / Avidity
Healthcomp Administrators
Healthfirst TPA / Ecom PPO
Health Network America
Health Plan Services / ACS the New England
Healthscope Benefits, Inc.
Hygeia Travel Health
Imerica / Healthtrans
Insurers Administrative Corp.
International Funding, Ltd.
John Alden (Fortis – refer to Assurant Health)
JSA P5 Utah
Managed Benefit Administrators & Insurance
Managed Care Administrators
Medical Benefits Administrators, DBA MedBen
Mayo Clinic Health Solutions, DBA MMSI
Mountain States Administrators
MID America
MS Administrative Services
Mutual of Omaha (refer to Coventry Health Care)
National Foundation Life Insurance Co.
National Health Insurance / Ecom
NCAS
New Era / Philadelphia Life / Ecom
NGS American
Noridian Benefit Plan Administrators
North America Administrators
NEF
Novanet
Outsource One Benefits
P5 Electronic Health Serices
Performax / CHF / Meritain Health
Philadelphia American Life
Preferred One Administrative Services
Principal Life insurance Company
Professional Benefit Services, Inc.
Professional Claim Administration (refer to Auxiant)
Regional Care, Inc.
Select Benefit Administrators of America
Shasta Administrative Serices
Significa Insurance Group
Southwest Services Administrators
Starmark
State General / Ecom
Summit Administration Services
Tall Tree Administrators
Taylor Benefit Resource
TBG Administrative Services
The Loomis Company
Trident Plan Administrators
True Choice / Healthscope
Trustmark Insurance Company
United Health International
United Medical Resource (formerly Iasis)
United Security Life
UMC (formerly Wausau Benefits / Fiserv)
Weyco, Inc. / Meritain Health
WMI TPA, Inc.
World Insurance (formerly Mid-America)
Zenith Administrators, Inc
BLUE CROSS BLUE SHIELD Third Party Payors:
AmeriBen Solutions, Inc.
Employee Benefits Administration
Fringe Benefit Services, Inc.
Gilsbar, L.L.C.
Health Now Administrative Services
Health Smart Benefit Solutions
Mayo Management Services, Inc.
Meritain Health, Inc.
Mountain States Administrative Services, Inc.
Pinnacle Claims Management, Inc.
Southwest Service Administrators, Inc.
Summit Administration Services, Inc.
Tall Tree Administrators
Web – TPA, Inc.
Zenith American Solutions
CIGNA Third Party Payors:
Southwest Service Administrators, Inc.
ACPN Third party providers:
AZ plans:
Alpha Vision Insurance
Ameriprise
Arizona Metropolitan trust
Continued AZ plans for ACPN:
Arizona Metropolitan Trust
Arizona Pipe trades Health and Welfare Fund
Assured Benefits Administrators
Basha’s Risk Management
Compstar Systems
IBEW 640
Insurers Admin Corp
Plumbers Local 8
Plumbers Local 88
ProCentury Company
Quik Trip Corporation
Republic Group
Salt River
Secura Insurance Company
Southwest Service administrators
Summit SRT Administrators
UFCW Employer Plan
Union Standard Insurance Group
Western Growers Assurance Trust
National Plans:
AHH
AIG
AIM Benefit Services
ALTRUA
Ameriplan
And many more. Please call our office or look on the ACPN website for details.
We do accept “out of network” authorizations for private companies we are not contracted with. Please call our office to obtain CPT codes patient will need for you to obtain the auth. Also, we accept self-pay patients. All non-contracted patients will be required to pay in full at time of appointment, and we will courtesy bill for them and refund the deposit.