Payments, Authorizations & Referrals

Payments

The patient’s copayment, co-insurance, and deductible amounts are due at the time of service.

Annual visits are covered at 100% by your insurance.  However, if you discuss items that fall outside of the annual exam guidelines your provider may bill additional charges to your insurance company which would result in a bill based on your insurance benefits.

Medication Prior Authorizations

If a prior authorization is requested, your insurance company is not refusing to pay but they are saying that they need proof from you and your provider that you have tried and failed other medications that they deem a reasonable substitute that are included on their formulary.

You are asked to come in because many times your provider will need your help in answering the questions required by your insurance on the prior authorization form.  These questions are not consistent from one insurance to another and your provider has no way to know what those questions might be.

A formulary is a list of medications your insurance will approve without requiring further information and typically require reasonable co-pay. You can download the formulary and prior authorization form from your insurance’s web site. Additionally, the formulary is included in the original information packet given to you when you signed up for your insurance plan. When your formulary changes your insurance updates it typically on-line.

If there is a reasonable substitute for the medication on the formulary, your physician will merely change the medication. If you have tried several of the medications on the formulary and they have not worked for you or you had problems with the medication on their formulary, with your help in answering the required questions on the prior authorization form, your provider will complete the form and fax it in to your insurance company. This process can take up to approximately 10 days to two weeks.

Bringing in your formulary each time you visit your physician will help your provider choose medications already approved by your insurance company thus negating the prior authorization process.

Imaging/Procedure Prior Authorizations

While insurance companies differ somewhat in the areas where they require prior authorization, the two most common are imaging procedures such as computerized tomography (CT) scans and magnetic resonance imaging (MRI).  If your insurance company requires a prior authorization for a procedure staff members will initiate the prior authorization process.  This process can take 10 days to two weeks to complete depending on the insurance carrier, diagnosis or medical necessity.  Prior to scheduling a procedure, it is good practice for patients to contact their insurance company to obtain a detailed explanation of their benefits.

Referrals

Some insurance plans require referrals for specialists.  If you require referrals to a specialist our offices will have a referral coordinator contact your insurance company to obtain a referral.  If you decide to see a specialist without a referral from your Primary Care Provider (PCP), please have the specialist contact your PCP’s office to initiate a referral.