Insurance
Plans | Questions for your
Insurance Company | Contact Us
The UNTHSC Pediatric Clinic participates with over 200 different
insurance companies. Each plan is different in the medical services
they cover, patient copayments charged, payment deductibles, and
how referral medical services such as laboratories, hospitals, and
medical specialists are obtained. Most insurance companies have
a directory of physicians from which you can select your physician.
Check your Insurance Company Physician Directory to see if our
Pediatricians are listed!
Most
insurance plans can be broken down into three types:
HMO |
PPO | Indeminity
Plan
Health Maintenance Organization (HMO)
- An HMO usually requires that you select a doctor to be your
Primary Care Giver (PCP). You are usually required to see this
doctor for all of your medical care needs. If you need to see
a specialist your PCP will usually accomplish a referral (approval
form from the insurance company) to see another physician. This
insurance plan will have a list of doctors from which you can
choose. You will usually have a copayment to pay for each doctor
visit.
Preferred Provider Organization (PPO)
- A PPO plan usually allows you to see any doctor you wish or
it may require you to see certain doctors that the insurance plan
has selected. Your PPO plan may or may not require a referral
or pre-authorization for medical services. You may or may not
have a copayment amount that must be paid prior to each doctor
visit.
Indemnity Plan
- This plan usually allows you to see any doctor you wish or at
times only doctors who are members of the plan. You will usually
have a deductible (an amount that may range from $100 - $500)
and a percentage of charges to pay after your deductible is met.
The clinic administrative and nursing services staff will assist
you in understanding your insurance coverage and medical services.
Remember it is really up to you to understand what your insurance
does and does not cover. Please read
your insurance plan policy and contact them with information about
coverage or payments that you do not understand. You
are responsible for paying amounts that are owed by you or for services
that are not covered by your insurance plan.
Here
are some things to ask your insurance company:
- Does my policy cover both sick and
well child visits? To what age and what amount? Some
insurance companies cover well child visits until the child reaches
6 years of age (after that you are responsible for paying) - some
plans cover the firs $200.00 of well child visits each year (after
that you are responsible for payment -- it adds up if your child
is under 1 year of age).
- Does my policy pay for all vaccines
recommended by the state the American Academy of Pediatrics?
Some insurance plans will pay limited amounts for immunizations
while some may not pay for all vaccines (Prevnar costs over $100
per immunization and children under the age of two usually receive
3 doses)
- Does my policy require me to see certain
doctors or laboratories for special care? For example
some insurance plans may have specialist physicians to care for
you but they are located some distance from your home. Some may
not have physicians in all special medical care fields that your
child may require.
- If I want to change doctors how long
does it take before I can see my new doctor? Some insurance
plans allow you to change doctors once per year while others may
allow you to change each month. Always ask when the new
"effective date" will begin. For example if
you call on September 10 and the insurance company states the
change will be "effective on October 1" you will need
to wait to see your new doctor until October 1. Your previous
doctor must provide care to you until the "next effective
date" begins. You may be responsible for paying for the doctor
visit if you don't see your assigned doctor (PCP) on the date
of the visit.
- How long do I have to enroll a new
child from their date of birth? Some insurance plans
provide coverage for up to 120 days from the day of birth before
you need to contact for enrollment. Other insurance plans may
only allow 30 days from the date of birth before your child must
be enrolled. Always check with your Human Resources Office or
Insurance Company when you have a "new family member".
Once again if you do not enroll the new family member within the
insurance company timeline you may be responsible for payment
(or you may have to wait until your next "enrollment period"
occurs at work).
The clinic staff will verify your insurance coverage at each visit.
If your insurance coverage has changed please let the staff know
upon your check-in. We will submit bills to your insurance company
for you. The clinic
staff will also ask that you pay any copayments, balances, deductibles
or cost shares you owe upon check in at the clinic for each patient
visit. We have signed contracts
with the insurance companies that require us to collect these amounts
during your visits ( or we could be in default of the contract).
Remember to bring in your insurance cards for each insured
member.
Remember it is your responsibility to
understand what your insurance does and does not cover. The clinic
staff will assist you as much as we can in understanding your insurance
coverage, your payment requirements, or how to arrange payment plans.
Check your Insurance
Company Physician Director to see if our Pediatricians are listed!
If you are unsure just give
the clinic a call (817) 735-2363 and we can answer many questions
that you may have.
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