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A Bright Future Pediatrics

Understanding Your Health Insurance Benefits: A Guide for Patients

In this ever-changing world of health insurance, it is imperative that you know and understand your health plan. You may ask yourself “how can I possibly handle that?” It’s actually quite simple if you start with the basics. Below you will find a brief guide to give you an introduction to health insurance.

Do you take my insurance?

A Bright Future Pediatrics accepts most major insurance plans, including, but not limited to:

  • Accountable PPO
  • Aetna HMO/PPO Option II
  • Averde Non-Gated PPO
  • BCBS PPO/HMO
  • Beech Street PPO
  • Cigna PPO/OAP/HMO
  • Coalition America (Formerly NPPN)
  • First Health/Coventry PPO-Dir Payors
  • First Health/Coventry PPO-Ntwk Lease Payors
  • Galaxy PPO
  • GREAT WEST
  • HealthEZ
  • HealthSmart GEPO/ACCEL(NORTH TEXAS HEALTCARE)
  • HealthSmart PPO/POS
  • Humana Choice Care PPO
  • IMS PPO
  • Independent Medical Systems - PPO
  • MultiPlan PPO
  • PHCS
  • PlanVista PPO (NPPN)
  • Principal Edge Network PPO
  • Principal Edge PPO
  • Texas True Choice PPO
  • Tricare
  • UMR
  • United Non-Options
  • United Options PPO
  • USA MCO
  • Viant/Beech Street/ppoNext

Prompt-pay discount is provided to self-pay patients when payment is made in full at the time of visit for our services.

The best way to know for sure whether we accept your insurance plan is to check your insurance company's provider listing. Call us if your insurance plan is not listed.

What if my child is ill and your office is closed for the evening or weekend?

A Bright Future Pediatrics offers extended urgent care and Saturday urgent care hours:

Extended Urgent Care Hours: Monday/Tuesday/Friday, 5 pm – 7 pm
Saturday Urgent Care Hours: 9:30 am – 12 pm

If you have an emergency medical need, please call 911 or go to the nearest emergency room. We have a physician on-call 7 days a week for emergencies only.  

If you have routine questions, please call during our office hours.

If you need to speak with our physician on-call for urgent matters only, please call A Bright Future Pediatrics at (972) 208-8668. All after-hour calls will be answered within a timely manner. There will be a $50.00 charge for all physician phone calls after regular business hours. 

If you have a question regarding medication dosage, please call your local 24-hour pharmacy or your insurance nurse line.

If you need routine medical advice outside of regular office hours, please call your insurance nurse line.

Will the doctors call in a prescription for my child?

If your child is in need of a refill, have the pharmacy fax a request to our office at (972) 208-3186. If authorized, one of our doctors will sign the request and fax it back to your pharmacy. If a new or recurring health issue arises, your child will most likely need to be examined by one of our doctors before a prescription can be written. Please call our office at (972) 208-8668 to schedule an appointment.

I have to work and cannot come to my child’s appointment. Can I send another adult in my place?

It is preferred that a parent accompany a patient to an appointment. We understand that circumstances may arise when a parent cannot come to the appointment. We require written authorization for anyone other than a parent to come to an appointment.

If the accompanying adult does not know the child’s medical history or current medications, there is a significant language barrier, or at the doctor’s discretion, we reserve the right to reschedule an appointment for a time when a parent can be present.

How can I get a copy of my child’s immunization record?

Every time your child receives an immunization in our office, we give you a copy of the updated record. If you wish to print out a copy of your child’s immunization record, you may now utilize our patient portal to print out a copy whenever you need.

How much of an over-the-counter medication should I give my child?

We have a handy, printable chart explaining the correct dosage for common over-the-counter medications.

If I have questions about my policy where can I get them answered?

If your insurance is provided through your employer, the human resources staff can assist you. If you purchased your insurance, the agent who sold you your policy should be able to answer your questions. Or you may contact your insurance carrier directly at any time. Typically their contact information is listed on the reverse side of your insurance card.

Where do I obtain information about my health plan?

Each subscriber in a health plan receives a policy handbook upon signing up for his or her insurance. If you receive health care benefits through your employer, they can provide you with a copy. Covered benefits vary from policy to policy and from insurance carrier to insurance carrier. It’s important that you read through your most recent handbook and know your policy, making notes of any questions you have.

How do I know if my policy changed?

Your insurance carrier must notify you in advance of any changes in your policy. It is your responsibility to keep current of those changes.

Isn’t my doctor’s office responsible for knowing my benefits?

No. Medical providers are not responsible for knowing your policy and what is covered or not covered. Patient benefits vary widely with hundreds of different plans available in today’s market. Physician offices bill your insurance as both a courtesy and convenience to you as a patient. However, your benefits are your responsibility to know and understand. 

Why does my doctor’s staff need to know my social security number?

Your doctor can legally request your social security number, and requires it to administer aspects of your health plan, such as obtaining prior authorizations for medical services. Every doctor’s office is required by law to maintain a high level of security over patients’ personal information. This information is never sold or provided to unauthorized individuals.

What are “prior authorizations”?

Many health plans require permission in advance of a patient receiving particular medical services in order for the service to be paid. Your medical provider usually will call to obtain authorization for a service, but it is your responsibility to know if your insurance requires prior authorizations.

What does “participating provider” or “preferred provider” mean?

This means that your medical care provider has a contract in place with your insurance carrier to provide health care services to you for a pre-determined fee schedule. Deductibles and co-payments still apply.

How can I find out if something is a covered service?

You can review covered benefits in your policy handbook or contact your customer service representative. They are responsible for helping you understand your policy.

Additionally, review the explanation of benefits that your insurance carrier sends you after you have received medical services. This will explain your charges and how it was reviewed and paid according to your policy by the insurance carrier. Any dollar amounts you owe will match the statement you receive from the medical provider, as the medical provider obtains their information from the insurance carrier.

What are deductibles, co-payments, and co-insurance?

Deductibles: This is a set dollar amount that is required annually to be paid by the insured. The insurance will not pay any of your claims until this amount is paid by the patient. The medical provider must collect in full and is not allowed to adjust off any portion of this payment. You can call the number on your insurance card and they will be able to advise you of your deductible. They can also tell you if you have satisfied your deductible for the calendar year.

Co-payments: A set dollar amount that you are required to pay according to your insurance policy at each office visit.

Co-insurance: The portion of medical expenses that you are responsible for after the deductible is met and the insurance has paid its portion. For example, your policy may read 80/20, meaning that your insurance will pay 80% of the claim and you will be responsible for the remaining 20%.

Your policy manual can provide you with this information. Your insurance company determines the amount you pay. Again, medical providers are not allowed to adjust off your co-payments or deductibles. It is your obligation to pay these amounts.

When is payment expected?

Payment for services received is expected at the time of service. In most instances, you should be prepared to pay for your office visit the day you visit your physician. If you have any questions about your physician’s payment policy you should ask the office staff prior to receiving treatment. You are responsible at the time of the visit for any deductible, copayment, or charges not covered by your insurance company.

Why was I billed for my newborn’s charges?

No insurance will add your newborn automatically. It is your responsibility to inform your insurance company to add your newborn baby. Most insurance companies will give you 30 days after the arrival of your newborn to add them to your coverage. However, not all plans will retro your coverage back to the birth. Always check with your insurance company for their requirements.

Why didn’t my physician advise me that the vision screen, hearing screen (OAE), or Visual Evoked Potential (VEP) test would not be covered under my insurance plan?

Since there are numerous health plans with different coverage, the physicians have no way of knowing each patient’s coverage ahead of time. It is the member’s responsibility to verify their coverage for annual physicals. You will be billed after the visit for any charges that are not covered by your insurance.

Why does it take so long to receive a statement from A Bright Future Pediatrics & Adolescent Medicine?

If a patient is covered under an insurance plan, a claim is generated within a few weeks of the time the medical services were received. Claims are sent either electronically or by paper, depending on the capabilities of the insurance plan.

Claims sent electronically will usually be paid within a 90-day time period. Claims sent via paper will usually take over 90 days before they will be paid.

If insurance request medical records or any additional information regarding the date of service, this can take additional time for the claim to be completed. If there is a portion left over that is the responsibility of the patient, a statement is generated. This could be 6 months to 9 months before all of the above activity is completed.

Why can’t the billing office change my diagnosis so my insurance plan will pay for the service?

Only physicians can diagnose patients. It is illegal to create a diagnosis just to satisfy an insurance company.