Non-covered services are your responsibility. Before seeing the doctor, we recommend contacting your insurance and verifying which services are covered under your policy. Although they won’t guarantee payment on a claim prior to the claim being submitted, they can give you a good idea of whether a type of service is covered (e.g.,  preventative care, immunizations, mental health, etc.).

Co-pays are out-of-pocket expenses that are part of your contract with your insurance. Co-pays are usually a specific dollar amount (e.g., $20.00). Your insurance card will usually specify what your co-pay is. You are obligated to pay your portion prior to insurance paying the rest of the claim. Co-pays are due at the time of service, prior to seeing a provider.

Most commercial insurance companies will send you an Explanation of Benefits (EOB) as soon as a claim has been processed. The EOB will show what (if any) was paid on the claim, what (if any) was denied and why, and what (if any) is your portion. Your EOB is usually sent prior to the response being issued to us, so you may see it in 1-2 weeks before the payment is posted to your account. Your insurance may also send a request for information (e.g., other insurance coverage) in the form of a letter, and your claims will be pended until they get the requested information. Always carefully read anything you receive from your insurance company and respond immediately in order to expedite claim response time.

There is a nationally based system (RBRVS) that gives a point value to each service we provide. These points are based on several different aspects of patient care including place of service, level of difficulty, the possibility of malpractice, time spent, etc.

Surgical procedures such as lacerations and fractures also include global packages such as a follow-up for a specific time after the procedure in their value. Our charges are based off of this point value system. Although each medical practice uses the same value system to determine their prices, it is against the law for us to share, or “price-fix”, this information with each other. This is why the same service may cost a different amount at a different doctor’s office.

Although we have specific prices assigned to each code we bill for, we can’t determine what the cost for your visit is until the physician has actually seen your child. There are different levels of office visits, which are determined by the complexity of the condition and/or time the patient is being seen for. There are additional costs for immunizations, medications, labs, etc. that are not known until the services are provided.

You may contact the Billing Office at (303) 853-3440 prior to receiving services for an estimate of charges, but a final determination cannot be made until the physician has seen your child.

An inclusive denial means that the insurance believes that one or more service that was billed should have been included in other services on the claim. An inclusive denial is something we will work out with your insurance through an appeals process. Until we have a response on the appeal you will not be held responsible for the charges that were denied as inclusive.

If your insurance upholds their original denial we will adjust the denied charges according to our contract with the insurance company. If they reverse their original denial, you may end up being responsible for part or all of the charge if it is applied to a co-pay, co-insurance or deductible, or if it is denied for another reason.

We are required by Federal Law to report the exact services provided and the exact reason for providing them. It is fraudulent to report a different procedure or diagnosis code in order to make a visit “fit” your insurance plan. The only time a service or diagnosis can be changed is if we originally reported them incorrectly to your insurance. We recommend contacting your insurance, prior to being seen, to determine whether a service is covered under your plan.

Mountainland Pediatrics accepts self-pay (uninsured) patients. Self-pay patients are required to pay at the time of service and will receive a 20% self-pay discount on the office visit portion of the bill.

Your insurance benefit manual will give you a good idea of which services are covered under your plan. When in doubt, call your insurance company. They can give you specific information regarding your plan benefits, although they will not guarantee payment until the claim is processed. If you know of specific services you would like to receive, the Mountainland Billing Department can provide the codes for those services so your insurance can give you more accurate information.

First, refer to your insurance benefits manual and make sure you understand your benefits. If, after verification, you determine that insurance processed the claim incorrectly, the next step is to call Member Services at your insurance company. They may be able to resolve the issue over the phone and send the claim back for reprocessing. You can also appeal, in writing, with your insurance company and provide documentation supporting your argument that the claim was processed incorrectly according to your benefits. The Mountainland Billing Department may be able to help you with this process but we recommend contacting your insurance company first.