Billing & Insurance FAQs

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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

·      AETNA no referral needed for PPO, yes for HMO

·      AMBETTER through Health Net.

·      APIPA ( see United Community Plan below)

·      ARIZONA FOUNDATION – no referral needed

·      ASSERTA- Mt Graham Emoloyer Contract Program. NOT direct cash pay program.

·      BANNER HEALTH -no referral needed- BLUE CROSS BLUE SHIELD no referral needed

·      BCBS marketplace ( need electronic referral through BCBS website from PCP)

·      CARE 1st Health Plan of Arizona (AHCCCS)- referral from PCP

·      CIGNA (HMO plans require referral from PCP)

·      C.M.D.P. (Requires Notice to Provider for visit)- no referral needed

·      FIRST HEALTH/COVENTRY/CNN- no referral needed

·      GEHA- no referral needed

·      GOLDEN RULE- no referral needed

·      GREATWEST- no referral needed

·      Health Choice ( AHCCCS) ( referral from PCP)

·      HEALTH NET (HMO plans require referral from PCP) HMO and PPO

·      HUMANA (HMO plans require referral from PCP)

·      Indian Health Services with AHCCCS (referral from PCP)

·      TRICARE (Prime plan requires prior authorization from PCM)

·      UNITED HEALTH CARE – all plans

·      United Community Plan-AHCCCS) Fractures only. ( requires referral from PCP)

·      United Community Plan - Other diagnosis can be seen at Children’s Clinic by our doctors. Phone 324-5437 for appointment at CRS.

·      UNITED MEDICAL RESOURCES (UMR) – HMO needs referral

·      UNIVERSITY FAMILY CARE ( AHCCCS) (Requires referral from PCP)

We are contracted with all AHCCCS plans except Mercy Care.

We are also contracted with a number of Third-Party Payers for Arizona Foundation, Blue Cross Blue Shield and Cigna.

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.