Insurance & Billing
We make every effort to keep down the cost of medical care while maintaining the highest quality of service. As a courtesy to our patients, our offices participate with the insurance companies and managed health care programs listed below. We submit claims once based on information you provide, so please be sure that you keep us informed of any changes to your insurance coverage. For your convenience, cash, personal checks and major credit cards are accepted. For questions regarding insurance participation, or to provide us with updated information about your insurance, please call (410) 451-2116 during normal business hours to speak with a Billing Office representative.
Aetna Better Health
Blue Cross/Blue Shield
Coventry Diamond Plan
First Health Network
Golden Rule (a United Healthcare plan)
Humana (Choice Care Network only)
Johns Hopkins Employee Health
MAMSI (a United Healthcare Plan)
Maryland Physicians Care
MDIPA (a United Co)
Medical Assistance of Maryland
Motor Vehicle Accident/Pip
One Net PPO (a United Healthcare Plan)
Optimum Choice (a United Healthcare Plan)
Oxford Health (a United Healthcare Plan)
Reach Program (Anne Arundel County only)
Tricare (Standard and Prime plan only)
Tricare US Family Healthplan
UMR (a United Healthcare Plan)
United Health Integrated Services (a United Healthcare Plan)
United Healthcare Community Plan (formerly Americhoice)
University of Maryland Health Partners (formerly Riverside Health)
The Pediatric Group uses Ancillary Services, Inc., (ASI) to provide courtesy insurance claims filing for patients. ASI is required by insurance contracts to follow all of their rules, policies and procedures. Because insurance plans vary widely, are individualized by employer groups, and change from year to year, in many cases you will need to contact your insurance company or employer's benefits department directly for questions regarding coverage. The information below should help you understand the courtesy billing service provided to you by your doctor's office. If, after reading this information, you still have questions, please use the "Contact Us" link for more information.
There are so many different insurance plans that it is not possible for your doctor’s office to know the specific details of each plan. By understanding your insurance coverage, you can know what types of medical care are covered in your plan.
Take time to read your consumer benefits guide, every year. It is better to know what your insurance company will pay for before you receive a service, have tests completed or fill a prescription. Some kinds of care may have to be approved by your insurance company before your doctor can provide them.
If you still have questions about your coverage, call your insurance company and speak with a member services representative for a more detailed explanation.
Remember that your insurance company, not your doctor, makes decisions about what will be paid for and what will not. In addition, your doctor, not your insurance company, decides what medical services you should receive in the interest of your health.
If you have questions about the clinical services or care you received at a medical practice, please submit your concern directly to the medical facility in writing.
Patient and Account Information
In order to provide you with courtesy billing services and to meet insurance company requirements, the medical practice where you receive care must have accurate insurance and demographic information from you at the time of your visit. It is important to note that you are ultimately responsible for full payment on your account. Some doctor’s offices may also charge a resubmission fee for denied claims based on incorrect information provided at the time of your visit.
Co-Pays and Deductibles
Your health insurance policy is an agreement between you and your insurance company. Insurance companies require subscribers to pay all co-pay and deductible amounts in full at the time of service. Your doctor’s office, according to their insurance contracts, must uphold this rule. If you have questions about your obligations, contact your insurance company prior to your visit.
We submit claims one time on your behalf, with the information given at the time of your visit, as a courtesy provided to you by your doctor’s office. If a resubmission is required based on new or corrected information you provide, many practices will apply a resubmission surcharge to your account. You are always free to resubmit a claim on your own, but the balance becomes your responsibility to pay if full payment is not received within the time period specified by the physician’s contract with your insurer. In such cases, we suggest that you pursue reimbursement directly from your insurer, or contact your employer's benefits department or plan sponsor for assistance.
Referrals and Prior Authorization
Referrals and prior authorization are required for many types of visits and insurance company requirements vary widely. You are responsible for obtaining the proper referral for your visit. Claims without proper referrals become your responsibility. Please review your plan benefits guide regularly and contact your insurance company for more information or prior to your visit.
Explanation of Benefits
After your appointment, and according to the insurance information you provide, your doctor’s office may submit a bill (also called a claim) on your behalf to your insurance company. A claim lists the services your doctor provided to you. The insurance company uses the information in the claim to pay your doctor for the services you received.
When the insurance company pays your doctor, it might send you a report called an Explanation of Benefits, or EOB, that shows you what it did. You need to be able to read and understand the EOB to know what your insurance company is paying for, what it’s not paying for, and why. An EOB is not a bill.
Your doctor’s office might send you a statement. A statement shows how much your doctor’s office billed your insurance company for the services you received and whether there are any outstanding amounts due for the services that were provided to you. After your insurance company pays your doctor, you may need to pay the doctor any balance due.
Keep in mind that not all insurance companies send EOBs, and not all medical offices send statements. You may receive one or the other or both.
Included below are links to a sample EOB and billing statement with information to help you understand them. You should use what you learn to review your EOBs and billing statements carefully. Here are some things to look for:
- If you have questions about why your insurance company did not cover something or about the amount you have to pay, contact your insurance company.
- If more than 60 days have passed and your insurance company still hasn’t paid your doctor, contact your insurance company. This amount may become your responsibility if your insurance company has not paid within a specified period of time.
- Charges for medical care are determined according to federal rules, insurance contracts and established standards of care. Charges may not be altered or discounted at any time based on a patient’s insurance type or preference. All medical services are provided and billed according to the same guidelines and protocol for all patients.
Finally, you should keep your EOBs and statements organized (e.g., filed by date) so that you can access them easily should questions arise.
All insurers have different rules and distribute different forms of "explanation of benefits" (EOB). These forms can be confusing and differ from insurer to insurer. If you have a question about an EOB you received from an insurer, please consult the insurance company for specific details. We are not able to provide interpretation or analysis of EOBs, or contact insurers on your behalf about your EOB or plan benefits. If you find your insurer is not responsive, we suggest your contact your employer’s benefits department or plan sponsor.
“Gaps” in Coverage Based on Best Practices
Your health insurance policy is an agreement between you and your insurance company. The policy lists a package of medical benefits such as preventive care, tests, prescription drugs and treatment services. The insurance company agrees to cover the cost of certain benefits listed in your policy. These are called “covered services.”
Medical offices follow established clinical guidelines and standards of care, which are not always fully recognized by insurers and employers or plan sponsors who purchase the coverage. There may be a gap between services you receive based on "best medical practices," including lab work and other tests, and the services covered under your insurance plan.
Amounts based on this gap are your responsibility to pay. The fact that your insurance plan may not provide coverage for certain services does not mean that you should not have received them according to established standards of care. We suggest that you contact your insurer, employer’s benefits department or plan sponsor if you have questions about why such recommended care is not covered under your plan.
Keep in mind that a medical necessity is not the same as a medical benefit. A medical necessity is something that your doctor has decided is necessary based on established standards of care and federal guidelines. A medical benefit is something that your insurance plan has agreed to pay for. In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy.
Certain situations can create complex reimbursement issues with insurance companies. Your medical practice may provide you with information about its policies for such services. These situations include the birth of a newborn, obtaining emergency services and presenting out-of-area or multiple insurances. For these situations, we suggest that, to the extent possible, you check with your insurer in advance to verify your coverage and benefits, and always be sure your physician has the proper insurance information for you and your family at the time services are provided. We are not able to perform follow-up or advocacy services for complex insurance issues.
Motor Vehicle Accidents and Personal Injuries
In the event of motor vehicle accidents and personal injuries, most practices do not bill personal injury insurance carriers (including auto insurance and workman’s compensation) or wait for the outcome of claims proceedings or lawsuits. In addition, many of these services may not be submitted to your personal medical insurance policy. Payments for such injuries are ordinarily expected at the time of the visit.
Many practices assess administrative charges for missed appointments, completion of forms, resubmission of claims to insurance carriers, late payments and returned checks.
Finance charges are often assessed by medical offices based on non-payment of services within a specified period of time. Your insurance company has agreed to pay your physician for the services you have already received. If this does not happen within a specified period of time, the amount due and subsequent finance charges may become your balance. It is your responsibility to contact your insurance company and ensure payment to your physician for the services that were provided to you.
Please consult the practice where you receive care to learn more about its policies.
In order to keep your health care costs down, we process information and inquiries as efficiently as possible. Because we deal with a large volume of information, please allow us time to access and review your account in order to fully to respond to your telephone or email inquiry. In some cases, for patient or privacy concerns, we may mail a response to you at the address you supplied letting you know the status of your account once it has been reviewed.