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Call the Billing Office on 303-853-3440

Financial FAQ: Frequently Asked Questions on Billing and Payments

What are co-pays and when are they due?

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 doctor.

What is co-insurance and when is this payment due?

Co-insurance is another out-of-pocket expense that may be a part of your contract with your insurance company and is usually a percentage of the allowed charges (e.g., 20%). Your insurance card may specify your co-insurance obligation or you may check with your insurance company for your obligation under your policy. Mountainland Pediatrics will submit a claim to your insurance for all charges. After payment and/or notification from your insurance company, we will bill you for what the insurance company has determined is your co-insurance.

What are deductibles and when are they due?

A deductible is a clause that you may have in your insurance contract that exempts your insurance company from paying an initial, specified amount (for example, you may be required to pay the first $100 or $500 of medical expenses incurred). Once you have met your deductible amount as specified in your contract, your insurance will pay claims within your plan provisions. We will submit a claim to your insurance company for the full charged amount so that they can credit the services toward your

Why am I getting a bill when I have insurance and/or Medicaid?

Our financial contract is with you, not with your insurance company. If there are any unpaid amounts you will be sent a statement to inform you of your account status. There are several reasons why you may be receiving a statement, even with insurance. Some of the most common are:
• Insurance has denied the claim.
• Insurance has applied the claim to a deductible.
• Insurance has not received a copy of your claim, usually due to incomplete/invalid information.
• Insurance has not responded to the claim within the time frame specified by state law.
• Accurate insurance information has not been provided; an old insurance is being billed.
• We have received a response from your primary insurance and are in the process of billing your secondary insurance or your insurance company may need information from you regarding coordination of benefits.
• Insurance has processed the claim and left a higher co-pay or co-insurance amount than what was paid at the time of service.

Please call the Mountainland Pediatric Billing Office at 303-853-3440 if there is any part of your bill that you do not understand.

Why do you need my Insurance card at every visit?

Insurance eligibility can change from day to day, so we must see your card to verify your benefits are active. Most insurance companies require healthcare providers to check your card.

Did you receive my payment/how do I know if you have received my payment?

If you've made a payment on your account and are no longer receiving a statement, it is because your payment zeroed out the balance on your account so a statement is no longer necessary. You can also follow your checking and/or credit card account to see if payments have been cashed or transmitted. Upon request, we can provide a report showing any and all payments received from you. As always, if you see any discrepancies please contact our Billing Office.

Can you bill my ex-spouse for this?

The person bringing the patient into the office, and who signs our financial agreement, is who we will hold financially responsible for any balances. You may have a divorce decree that states your ex-spouse is responsible for part or all of your dependant's medical bills, but Mountainland Pediatrics doesn't have the authority to enforce a divorce decree. It is up to you, your ex-spouse and the court to work out details and enforcement of a divorce decree. We will send correspondence to the person we have a financial contract with. You may forward the statement to your ex-spouse if they require a bill in order to pay their portion, but we do not bill them directly.

When should I add my newborn to my policy?

Some insurance companies require as little as 24 hours' notice of the addition of a baby. Please check with your insurance company on its requirements and be sure to meet the deadline!

How do I know when my insurance has responded to a claim?

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 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.

Why do you charge what you charge for services?

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, possibility of malpractice, time spent, etc. Surgical procedures such as lacerations and fractures also include global packages (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.

How much do you charge for office visits and/or other services?

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 also additional charges 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.

What if my insurance denies a service as non-covered?

Non-covered services are your responsibility. Before seeing the doctor, it is always a good idea to check with your insurance and verify 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 or not a type of service is covered (e.g., preventive care, immunizations, mental health, etc.).

What if my insurance denies a service as inclusive?

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 the 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 off according to our contract with them. 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.

Can you change how you billed my child's visit so my insurance will pay the claim?

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. You may want to check with your insurance, prior to being seen, to determine whether a service is covered under your plan so you know what to expect.

Can I still be seen if I don't have insurance?

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. This is a collection savings that we are able to pass on to you because we do not have to spend time or resources collecting after the fact.

How do I know what services are covered under my insurance plan?

Your insurance benefit manual will give you a good idea of which services are covered under your plan. When in doubt, call your insurance. 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.

What can I do if I don't agree with how insurance processed my claim?

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 Billing Department may be able to help you with this process.