Insurance FAQs

What is a health insurance policy?
Your health insurance policy is a contract between you and your health insurance company. It is an agreement requiring your health insurance company to pay for covered medical care as long as you pay your portion of the policy. The health insurance company may not pay for every service you received. It is important for you to understand the specifics of your coverage, as you are responsible for paying any medical costs that the health insurance company does not pay for.
What is a Co-payment/co-pay?
The part of your medical bill you must pay at the time of service. This is a pre-set fee determined by your health insurance policy.
What is Coinsurance?
The part of your bill, in addition to a co-pay, that you must pay. Co-insurance is usually a percentage of the total medical bill – for example, a plan with 80/20 coinsurance would require you to pay 20%. Co-insurance frequently begins once a deductible has been met.
What is deductible?
The amount of money you must pay before your health insurance company starts to pay – for example, $500 per individual or $1,500 per family. In most cases, a new deductible must be satisfied each calendar year. It is important to ask your insurance provider what services count towards your deductible (e.g. prescriptions, well visits, labs, etc.).
What are non-covered (excluded) services?
Cost for treatment that your health insurance company does not pay. You may wish to determine if your treatment is covered by your health insurance policy before your appointment.
What is secondary insurance?
Secondary insurance is any insurance that could serve as a “back up” if the primary insurance does not cover certain things. Parkside does not file secondary insurance.
What is an HSA account?
A Health Savings Account allows you to set aside pre-taxed earnings until you need it for qualified medical expenses
What is an FSA account?
A Flexible Spending Account allows you to set aside pre-taxed earnings (normally from your paycheck for qualified expenses e.g. medical, childcare, etc.) that occur in the same year.
How is my doctor’s office paid?
While you are responsible for the cost of your care, your doctor’s office will make every effort to seek payment from your health insurance company for the amount owed under your policy. Because of this, doctor’s offices encourage you to provide thorough and timely patient and policy information.
What is coordination of benefits?
Many health insurance companies require you to fill out a form that tells the company whether you or a family member have other health insurance. Your health insurance company needs this information to work with other insurers to determine which company pays for what services. It is important that you fill out this form and return it to the health insurance company or call them directly to give them this information. Otherwise, your medical bills may not get paid or payment may be delayed.
What is an EOB?
How to read an EOB:
CPT Codes: Services provided by Parkside that are billed to Insurance.
Billed amount: The amount that is billed to Insurance. Parkside’s fee for services.
Fee Schedule: The contracted allowable rates given to us by the insurance. Every insurance follows a fee schedule.
Allowed amount: An insurance company’s contracted rate for a service. The maximum an insurance will pay for a service.
Deductible: a specific contracted amount of money that the insured must pay before other benefits apply.
Coinsurance: a type of insurance in which the insured pays a share of the payment made on a claim. Example Insurance will pay 80% and the patient is responsible for 20%.
Copay: amount put to patient responsibility that is required by the insurance company.
Adjustment: The difference in what Parkside billed the insurance and what the Insurance allowed.
*Example: Parkside bills Insurance $100.00 for an office visit. The Allowed amount is $72.00. Parkside adjusts (or writes off) $28.00. The adjustment is $28.00
Other Adjustments: Bundled services. Some insurance companies let us know ahead of time that the payment for some services, are included in the payment of another service.
*Example: Patient is seen for an office visit and needs a lab. Some of the labs codes will not be paid. Insurance companies will bundle the services and have us adjust off what was billed.
Patient Responsibility: co pays, coinsurance, deductible, non-covered services.
Preventative Visits: Consumers have heard that the health care law requires health insurance plans to cover 100% of the costs for preventive care. However, a question we often hear is, “How do I know what is considered preventive care?”
Preventive care is the care you receive to prevent illnesses or diseases. It also includes counseling to prevent health problems. Preventive care may also help reduce your health care costs down the road if you catch a problem early, or if an immunization keeps you from getting a serious illness.
What is ICD-10? – Updated 10/01/15

In short….

  • Don’t worry… First of all, you might not notice a change at all!
  • How billing works… When you bring your child to a visit, we communicate their condition through codes to your insurance company.
  • What’s new… There is a new coding system that is being implemented across the country called ICD-10.
  • We have you covered… At Parkside, we have a well skilled team who have already taken care of all of our updates, your Parkside providers are trained, and our team is here to help you in any way we can.
  • What you may see… As insurance companies update their systems there may be a delay in the processing of claims. If this happens (which it is very likely) then it will then cause your Parkside statement to be delayed as well. (The domino effect)
  • What you can do… Please contact your insurance company for any concerns relating to your claim.
  • We are here to help! You can also check the back of your insurance card for contact information.

In depth…

There is a new set of diagnosis codes coming our way. The International Classification of Diseases (ICD) is a classification system that allows health care professionals to diagnose and classify diseases, illnesses, and injuries to a more accurate degree of specificity. Currently, the United States uses ICD-9 and has been using this set of codes since 1979. ICD-9 is very limited in what diagnoses our providers can choose. ICD-10 is MUCH, MUCH more specific. America is currently one of the only countries in the world who has not yet switched to ICD-10. But don’t worry, we are finally catching up! Starting October 1st, 2015, the United States will be switching our code sets to ICD-10.

Now, we’re sure you’re wondering, “What does this mean?” and “How will this affect me?” All that this means for you is that our Parkside providers will be able to provide you with an even better level of care. The diagnosis codes that we use will be able to better portray the severity, complexity, and gravity of your child’s condition, and to communicate their condition to your insurance company.

Our hope is that this will not affect you at all! We have a special ICD-10 team here that has been working and training for months to make sure that Parkside Pediatrics is prepared for this transition. We have made sure that every department at Parkside is updated and ready for October 1st. In addition, our billing staff is currently in the process of testing claims with some of our major insurance companies as well. With this being said, we know our insurance companies are experiencing this same update and we do not know exactly how they will handle this change. We know that your Parkside team has prepared well so we can help make it a smooth transition.

We have been notified by several insurance representatives and coding specialists that there may be a delay in billing during the implementation of ICD-10. We wanted you to be aware that if this is the case and insurance companies do take longer to process your claims, this could result in a delay in Parkside’s billing as well. It is possible that you could receive a statement for a visit that happened two or more months prior. We do remain hopeful that this transition will take place smoothly, and with few to no glitches, so that your claims will continue to process in a timely manner!

We ask that you be patient with us as we adjust to this change right along with you. As usual, we recommend that you touch base with your insurance company about the changes and any questions you have about your specific plan. It’s always in your best interest to understand what is included/excluded in your health plan.