Billing

We are contracted with many insurance carriers and are pleased to bill them directly for the patient. It is best to check with insurance company prior to scheduling an appointment just to be sure that the visit coverage is active and the visit will be covered.

Please Note: The practice is currently not able to accept certain HMO plans or new CCAH/Medi-Cal plans.

Please provide us with a copy of insurance card(s) and parent’s photo ID or Driver’s license. If a copayment or deductible is part of the insurance plan, we require that the patient’s portion is paid at the time of service.

The patient has secondary insurance? No problem…Be sure that both insurance companies know which insurance is primary and which insurance is secondary.

For example, insurance companies follow the birthday rule when both parents have insurance on a child. Whichever parent has the birthday that falls earliest in the year, is the holder of the PRIMARY insurance. The parent with the birthday that falls later in the year is the holder of the SECONDARY insurance.

If the child has insurance through a parent and also has Medi-Cal or Central California Alliance for Health (CCAH), the CCAH insurance is always secondary to the private insurance. To avoid problems at appointment time, CCAH must be made aware that the patient has other health coverage or primary insurance prior to scheduling an appointment.

Once the primary insurance has processed the claim and provided us with an explanation of benefits (EOB), we will then bill the secondary insurance along with a copy of the EOB from the primary insurance carrier.

There are now some HMO plans which cover medical practices in Monterey County. Please be sure that the name of one of our physicians is listed on the card prior to scheduling an appointment. Some HMO Plans do not provide coverage in Monterey County. Patients with an HMO Plan/Insurance card from outside the area are encouraged to contact the insurance carrier for details of the HMO coverage. Any unpaid charges and balance left by the insurance company will be the responsibility of the patient.

Note: It is the responsibility of the parents to understand the child(ren)’s insurance coverage. If the patient’s insurance card has an outside physician named on the card, coverage for our office will not be paid by the insurance carrier. The practice will not bill any insurance that has an outside doctor listed on the card.

Along the bottom of the statement parents will notice the aging of insurance claims and patient responsibility. Insurance amounts are from claims which are still outstanding from the insurance company. If the claims are under 60 days old, the patient may wait until the insurance company sends an explanation of benefits (EOB) to the patient and sends the payment to our office.

The patient is not yet responsible for these amounts. However, if there is an amount under the heading 60 days or older, please contact the insurance company to check if there is a problem with a claim. Once claims are paid, the amount due from the patient will then shift to the “PATIENT” patient responsibility showing on the statements. The patient is responsible for the amount listed in the lower right hand box labeled, “PLEASE PAY THIS AMOUNT”.

Once the explanation of benefits (EOB) and payment are received from the insurance company, the balance is then immediately due and payable by the patient within 30 days.

Once a denial is received from an insurance company the balance is immediately the responsibility of the parent/guarantor. The balance is then due and payable within 30 days. It is the responsibility of the parent/guarantor to handle any disputes directly with the insurance company. A patient service phone number is located on the back of the insurance card.

If the patient has no medical insurance, payment for services is to be paid at the time of the visit. This is true unless arrangements have been made with our financial department prior to the visit. Children without insurance are eligible for free vaccinations under California’s Vaccines for Children (VFC) program and available through Monterey County Department of Health. If you have questions, please inquire with the receptionist.

Most health insurance provided by an employer or privately obtained, allows 30 days to add a newborn to an insurance plan. It is the parent’s responsibility to contact the insurance company as soon as possible after the baby is born in order to have the coverage retro-activated back to the baby’s date of birth.

Please note:

• If a parent misses this 30 day window and fails to inform the employer and/or insurance carrier, the coverage will not be in effect for the child and the parents will be responsible for the balance on the account.
• Babies are very rarely covered under grandparent’s insurance even if the mother is covered by her parent.

If the baby will have coverage through Central California Alliance for Health (CCAH), the parent must contact his or her case worker immediately to enroll the baby as an individual. The baby is only covered for the first 30 days under the mother CCAH coverage.

Parents/guarantors may request the option of paying the balance in monthly increments by contacting the billing department to set up a specific payment plan. The billing department can be reached Monday – Friday from 9:00 a.m. – 5:00 p.m.

Pacific Coast Pediatrics will not be responsible for disputes regarding divorce, custody, and financial responsibility. The custodial parent, and /or the parent who brings the child or children to the clinic will be responsible for the account. The office will have no involvement in any financial responsibility disputes between parents and/or insurance subscriber responsibility.

It is our clinics policy to charge a $25.00 Not Sufficient Funds (NFS) fee for all returned checks. This fee is billed in addition to the original amount owed.