Insurance

Swimming BabyNorth Atlanta Pediatric Associates is enrolled in numerous managed care insurance programs. We are pleased to provide this service to our patients; however it is impossible for us to keep track of each plan’s individual requirements. Please make sure you understand the benefits and requirements of your plan and be aware of any changes that may occur over time. Plans differ depending on the type of contract your employer may have negotiated. Most plans have stipulations regarding how often, where, and by whom medical services may be rendered. For example, some plans do not cover the hearing and vision testing we provide beginning at 4 years of age. Some plans have wellness maximums based on a dollar amount or on a set number of visits within a certain time frame. A majority of plans require wellness visits to be at least one full calendar year from the last wellness exam in order to be covered; and some wellness visits may not be covered over a certain age. Your insurance is a contract between you and your insurance company; therefore, it is very important that you take an active role in understanding your benefits.

Newborns
It is important that you add your newborn to your insurance policy within the first 30 days of life. This will prevent any lapse in coverage. Contact your human resources department for the proper paperwork and their guidelines.

Primary Care Physician
If you have a plan that requires a primary care physician (usually an HMO or POS), you must specify your selection to the insurance company. The majority of companies will not back date a primary care physician selection, so it is important that this is specified before you are seen by one of our providers in order for the claim to process correctly. Some of the newer plans have an option where a primary care physician is not required; however, specialist copays may apply.

Please visit our Frequently Asked Questions section below if you have questions that were not answered in the above information. If you have specific questions regarding a bill you received from our office, please contact our business office at 404-917-0964.

Frequently Asked Questions

Q: What is COB?
A: COB stands for Coordination of Benefits. Most insurance companies send out a yearly questionnaire inquiring whether you have other insurance coverage. Claims are typically pended once this information has been requested from the member and will not be paid until the policy gets updated. It is the policyholder’s responsibility to update this information to ensure proper claims processing. The policyholder will be held responsible for charges until they update this information with the insurance company.

Q: My child has double coverage. How do I know which one is primary?
A: When there is double coverage, the “birthday rule” applies. The parent whose birthday falls earlier in the year is named as the primary insurance and the other is secondary. North Atlanta Pediatric Associates does not file secondary insurance claims.

Q: I have received a bill from your office. Did you file my insurance? A: If we participate with your insurance company, we will file your insurance for each visit. Claims are submitted daily. You will not receive a statement unless we have received correspondence from your insurance company stating that a balance is due from you.

Q: My bill states a deductible and/or coinsurance applied. What does that mean? A: A deductible is the amount of out of pocket expenses you must pay the doctor or hospital before your policy will pay any benefits. Co-insurance is the percentage that the insurance company will pay from the total claim. It is the ratio of splitting the bill between the insurance company and you. Because each plan differs, you will need to check with your insurance company or your schedule of benefits to find out what services apply to your deductible or coinsurance.

Q: What is a high deductible Health Plan (HDHP)? A: This is a plan that features higher deductibles than traditional insurance plans.  These plans can usually be combined with a health savings account or a health reimbursement arrangement to allow you to pay for qualified out of pocket medical expenses on a pre tax basis.

 

List of Insurance Carriers

North Atlanta Pediatrics has contracts with the following insurance carriers.

  • 1st Medical Network (aka Medical Mutual of OH and Supermed)
  • Aetna
  • BCBS PPO / Federal
  • BCBS HMO/POS as of 3/1/09
  • BCBS Exchange Products (Healthcare Marketplace) – OPEN ACCESS
  • Beech Street PPO
  • Cigna
  • Cigna/Great West
  • Coventry HMO
  • Coventry National (formerly First Health and Southcare)
  • Humana – all commercial plans
  • Humana Exchange (Healthcare Marketplace) - National POS – OPEN ACCESS only (We are not on Humana X)
  • Lifewell PPO/HMO
  • PHCS/Multiplan (Private Healthcare System)
  • UHC

Marketplace Products & Plans

Quite a few of the new marketplace products cover a limited service area or in network services only. These plans may require PCP selection, Referrals and or Prior Authorizations. Please choose your plan carefully.

We are in network with the following plans on the Marketplace:

  • Humana National Preferred (POS) Bronze, Silver, Gold and Platinum.
  • UHC Compass
  • Cigna Local Plus
  • CoventryOne HMO
  • BCBS Pathway X

We are NOT in network with Alliant, Ambetter, Assurant, Kaiser or Humana HMOx.

Please be aware that the above list is subject to change at any time. North Atlanta Pediatric’s participation with your insurance carrier does not guarantee payment of services. You are ultimately responsible for all charges.

 

Financial Policy

The following is a statement of our Financial Policy which we require you to read and sign prior to treatment.

Due to frequent changes in health insurance coverage, we require that you provide proof of insurance coverage at each visit. If you do not have insurance, are unable to provide proof of insurance coverage, or are on a plan in which we do not participate, full payment is required at the time of your visit.

All co-payments are due at the time of service. These fees cannot be waived. All co-pays not collected at the time of service will incur a $10 billing fee. Please be aware that some services provided may be non-covered services and not reimbursable by your insurance. You are personally responsible for these services. For your convenience we accept cash, check, Visa/Master Card (including debit cards), American Express and Discover.

If we are a participating provider, we will file your insurance for each visit. Should there be a dispute with your insurance company, our insurance department will attempt to resolve it for you. During this time, the balance may be transferred to your responsibility. Please note that your insurance policy is a contract between you and your insurance company, therefore, your balance is your responsibility.

Missed appointments for routine/preventive care are very disruptive to our office and deprive others from an appointment to see the doctor. Twenty-four (24) hour cancellation for routine check-ups is required to avoid the $80 charge.

Financial arrangements for large balances can be made through our payment program. Failure to resolve any past due accounts, including returned checks may result in referral to a collection agency. Any family whose account is forwarded to a collection agency may be dismissed from our practice.

Requests for transfer of medical records will incur an administrative fee of $15 per child up to two and $35 for 3 or more children. An immunization record can be provided at no charge for active patients.

Effective September 1, 2005, there will be a $5 administrative fee to complete forms (camp, school, sport, etc.) not associated with a routine visit. There is no charge for the required state forms, unless they must be replaced. We require 72 business hours to complete the forms. “Rush” forms incur a $20 fee.