The UNTHSC Pediatric Clinic participates with over 200 different insurance companies. Each plan is different in the medical services they cover, patient co-payments 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.
Health Maintenance Organization (HMO)
-An HMO usually requires that you select a doctor to be your Primary Care Provider or 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 co-payment 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 co-payment amount that must be paid prior to each doctor visit.
-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/s are 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.
Questions to ask your insurance company:
1) 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 six years of age (after that you are responsible for paying) - some plans cover the first $200 of well-child visits each year (after that you are responsible for payment -- it adds up if your child is under one year of age.)
2) 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 three doses.)
3) 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.
4) 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 10th and the insurance company states the change will be "effective on October 1st", you will need to wait to see your new doctor until October 1st. 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.
5) 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, please call the clinic at: 817.735.2363 for assistance.