Insurance

Answers to Your Insurance Questions

If you have questions regarding a bill, please call our Central Billing Office at 404.705.8990.

None of us may like to talk about the details of insurance coverage, but let’s face it: understanding your plans will prevent billing surprises, and you need to be aware of what your insurance program covers and what it doesn’t. We are here to help in any way we can, but we could never be expected to understand the coverage details of every insurance program. You need to know your own plan!

 

What is a “responsible party”? Remember that while we’re happy to accept and process insurance for payment, you (as the “responsible party” on your patient information forms) are ultimately responsible to make sure we are paid for the services we provide for your child. Your relationship with your insurance company is private, and because of government privacy regulations, we are not allowed to negotiate with your insurance company on your behalf. We are here to help in any way we can, but remember, there are hundreds of different plans, all with different rules, and different items that they will cover just here in Atlanta. It's important that you know your own plan, because due to the large number of variables that often change many times a year, we cannot be responsible for knowing the details of your plan. You are the responsible party.

 

Can Northside Pediatrics master the details of my insurance plan for me? To accommodate the needs of as many patients as possible, Northside Pediatrics has enrolled in numerous managed care insurance programs. We are pleased to be able to provide this service to you, but it is impossible for us to keep track of all the individual requirements. Each plan has different stipulations regarding how often, where, and by whom medical services may be rendered. Even within the same insurance company, the plans differ with the type of contract you or your employer has negotiated. Providing quality medical care for you and your family will always be our primary concern, not the details of insurance programs.

 

Why is it important to know what your insurance plan covers? We may recommend or render medical services that are not covered by your insurance plan. For example, should your insurance carrier require you to use a specific lab or other outside facility, it is your responsibility to know the requirements of your plan. Failure to do so may result in charges your insurance company does not cover. Most managed care plans require that we receive authorization for referrals to a plan's list of subspecialists. These authorizations must be received well in advance of your appointment with the subspecialist. If a subspecialist is not on your "list" or if authorization is not received in advance, you will be required to pay out of pocket for the appointment. Other services that we provide which may not be covered by your plan include counseling for behavioral or learning problems, including ADD, extended telephone conversations, and written correspondence. You will be billed for these services directly. Again, please make every effort to become familiar with the benefits of your plan.

 

How will we work together on insurance and payment issues? We will ask to see your current insurance card at each visit. Your insurance information may change several times throughout the year. By requiring you to show your card each visit we insure your visit will be billed with the appropriate information to get your claim paid correctly. If you do not have your insurance card when you visit, your appointment will be considered a “self-pay” patient for that visit. “Self-pay” means you will have to pay for your visit in its entirety the day of service, and we will give you a record of your payment you can file with your insurance company for reimbursement.

 

You are required to pay for office visits or your required co-pay amounts by cash, check, money order or credit card. Please be prepared to pay at the time of the appointment. If you do not pay your co-pay or any outstanding balance due on your account at the time of your visit, we will be glad to bill you, but a $25 billing fee will be added to your account. This fee is not billable to insurance and will be due from you.

 

Most insurance plans reimburse us a contractually agreed discounted amount for our medical services. We are not able to "balance-bill" you for these services, if we hold such a contract with your insurance company.

 

Remember, if you have questions regarding a bill, please call our Central Billing Office at 404.705.8990.

 

Which plans reflect the current membership of Northside Pediatrics physicians? The list below is subject to change, so please contact one of our offices for the most recent information. Current plans include:

 

• 1st Medical Network (a.k.a. GA First/MRN) (PPO)
• Aetna (HMO, PPO & POS)
• Beechstreet (PPO)
• Blue Cross Blue Shield (HMO/POS, PPO, Blue Direct, Blue Open Access)
• Beechstreet (PPO)
• CCN
• Champus/Tricare PPO (Standard Only)
• Choice Care (PPO) - (f.k.a. Employers Health)
• Cigna Healthcare of Georgia (HMO, POS & PPO)
• Coventry Healthcare (HMO and POS)
• Employers Health Network - EHN (PPO)
• Evolutions Healthcare System (PPO) - (f.k.a. Guardian Resources)
• First Health (PPO)
• Galaxy Health Network(PPO) (f.k.a. Managed Care Inc.)
• Great West Healthcare (PPO, HMO, POS) - (f.k.a. One Health Plan)
• Health Network of America (PPO)
• Humana (POS and HMO)
• Kaiser (POS)
• Lifewell Health Partners (POS & HMO)
• Multiplan (PPO) (Merged with Preferred Plan of GA-PPG)
• Nova-Net (PPO) - (f.k.a. Special Net)
• PPO Next (PPO) - (f.k.a. Preferred Health Network & Healthstar)
• Private HealthCare Systems PHCS (PPO Only)
• Unicare (PPO)
• United Healthcare of Georgia (POS, HMO & PPO)
• USA Managed Care Organization (PPO)