Frequently Asked Questions for Patients
Most Popular
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How much will my insurance pay?
In most cases your provider is out of network and unfortunately will NOT be able to inform you an exact reimbursement amount for services provided. Out of network reimbursement amounts are based on a usual and customary that only your insurance has privilege to. In some cases your insurance will provide the reimbursement amount to their members.
Contact your insurance provider member service department directly. Inform the insurance representative that your provider is out of network and you would like to know how much will be paid for your care.
Below are the CPT codes you will need.
59400 which includes prenatal care, delivery and postpartum care.
59426 which includes ONLY prenatal care
Once a dollar amount has been provided, minus your deductible and / or coinsurance amount from that amount and the balance will be the amount paid out. IF your deductible is higher than the dollar amount provided 0.00 will be paid out and applied to your deductible. -
What type of plan should I look for?
The plan type that works best for the natural birth and/or care using midwives, birth centers, home births, doulas and naturopaths are:
PPO / POS plans
Plans that have out of network benefits
Has maternity benefits
NO exclusions or pre-existing
Specifically cover physicians that Naturopaths
I can NOT provide advice on which specific plan to choose but as long as the plan is NOT a state Medicaid or Medicare plan and ONLY a commercial plan such as but not limited to:
United Health Care
Aetna
Blue Cross
Health Net
Any commercial plan name that covers the above list will be accepted. Choosing your deductible should be based an amount that you can pay as it will be due before insurance makes any payments towards your claims. *Deductible that are 4,000.00 and higher provides less provider/patient reimbursement.
There is no way to inform you IF your provider will be covered OR provider specialty prior to signing up for the policy OR requesting a benefit book from the insurance carrier. -
What's next and what should I expect?
PRIOR TO YOUR BIRTH/DELIVERY Verification of Benefits
If you are interested in knowing if your midwife/provider is a covered provider and/or how your insurance will play a part in coverage/reimbursement for the care provided, this should be done prior to you delivering, BUT is NOT a required action. Please use the link below to proceed with the verification process.
https://www.favoredmedicalbilling.com/verifymybenefits.php
*IF your provider name is NOT listed, please select "MY Midwife is NOT listed"
*IF you already have your benefits, PLEASE do not complete the form attached to the above link.
AFTER YOUR DELIVERY
Claim Submission for Provider & Birth Center Once you have given birth and are ready to submit your claim to insurance for processing/reimbursement, please use the link below. Please note that claim submission should only be requested AFTER you have given birth OR if you have transferred care.
https://favoredmedicalbilling.com/ClaimSubmissions.php
Office/Home Visit Services & HSA /Flex Spending Account $50.00 Provider Only
For extra care such as well exams, PP care past global period, etc., claims can be submitted for the provider only to obtain reimbursement. Please use the link below.
https://favoredmedicalbilling.com/ClaimSubmissions.php -
My insurance says they cover at 100%. Is this true?
Your plan may state that they reimburse at 100% / 40% / 30% etc.. , BUT at the allowed amount of your insurance plan, and not at the provider's billed amount.
In most cases your provider is out of network and unfortunately will NOT be able to inform you an exact reimbursement amount for services provided. Out of network reimbursement amounts are based on a usual and customary that only your insurance has privilege to. In some cases your insurance will provide the reimbursement amount to their members.
Contact your insurance provider member service department directly. Inform the insurance representative that your provider is out of network and you would like to know how much will be paid for your care.
Below are the CPT codes you will need.
59400 which includes prenatal care, delivery and postpartum care.
59426 which includes ONLY prenatal care
Once a dollar amount has been provided, minus your deductible and / or coinsurance amount from that amount and the balance will be the amount paid out. IF your deductible is higher than the dollar amount provided 0.00 will be paid out and applied to your deductible. -
Connect with Your Insurance
Claim Status Check
Thank you for your inquiry regarding your submitted claim. Because your insurance requests 30 business days to process your claim, Favored Medical does not provide claim status prior to 30 business days of submission. You are welcome to use the link below to create an account directly with your insurance plan to track your claim process or you may contact your member service department using the phone number from the back of your insurance card.
United Health Care Member Account
Cigna Health Care Member Account
Health Net Care Member Account
Humana Health Care Member Account
Blue Cross Blue Shield of Arizona
Anthem Blue Cross & Blue Shield
Claims process:
1. Your claim is submitted within 48 hours of receipt to Favored Medical Billing to your insurance plan.
2. Your claim is received and logged with a claim number by your insurance provider within the first 7 business days of receipt.
3. Your claim is then "worked" for processing .. 30 business days later
4. Your claim is processed, either with payment or towards your deductible
5. Paid claims take an additional 10 business days for a check to be released and mailed.
6. Please allow proper mail/delivery time At 31 business days
If you have not received any correspondence from your insurance and do not see your claim on file (if being tracked), please contact Favored Medical Billing for proper follow up.
Authorization
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What is a gap exception?
A gap exception request is the submittal of an authorization, requesting your insurance to process claims submitted on behalf of your out of network provider using your in network of benefits.
IF have obtained a gap request, you can ONLY use that Gap Auth for:
The Provider in which the Gap Auth Number is under For the specific Care / CPT codes you provided or was provided to you by the payer whom authorized the care During the time frame the auth is covered
*IF you have obtained a gap, it is important that you provide that information at the time of billing your claim to avoid payment delays. -
Authorizations
Authorizations that are obtained by Favored Medical Billing are specifically for your provider and specifically for the the care and service they provide.
The authorization provided should ONLY be used for the intended provided and care.
The authorization process is NOT a guarantee of payment and is decided by your insurance provided. The time frame requested for response is 21 business days. Gap Authorizations does not eliminate financial responsibility, but allows your claims to be processed at the in-network.
Benefits
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What is benefit verification?
Benefit verification is the process in which FMBS obtains your in network as well as your out of network benefits to assist in determining out of pocket cost to your provider or potential insurance reimbursement. (reimbursement based on client/provider agreement)
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When should I request a benefit verification?
Once you have decided on a provider of care, the next step is verifying your coverage to sure your provider will be covered by your insurance plan.
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Contracted/Gap Provider
In the event your provider accepts a GAP authorization or becomes contracted with your insurance payer prior to OR during your care it is important to know that your financial responsibility may change. Because your provider is now contracted or GAP approved the amount they collect can ONLY be the amount outlined in you IN-Network benefits. NO monies outside of what is due of your in-network coverage can be collected. IF you are unsure of that amount, please have your account verified OR re-verified.
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What type of plan should I look for?
The plan type that works best for the natural birth and/or care using midwives, birth centers, home births, doulas and naturopaths are:
PPO / POS plans Plans that have out of network benefits Has maternity benefits NO exclusions or pre-existing Specifically cover physicians that Naturopaths
I can NOT provide advice on which specific plan to choose but as long as the plan is NOT a state Medicaid or Medicare plan and ONLY a commercial plan such as but not limited to:
United Health Care Aetna Blue Cross Health Net
Any commercial plan name that covers the above list will be accepted.
Choosing your deductible should be based an amount that you can pay as it will be due before insurance makes any payments towards your claims. *Deductible that are 4,000.00 and higher provides less provider/patient reimbursement.
There is no way to inform you IF your provider will be covered OR provider specialty prior to signing up for the policy OR requesting a benefit book from the insurance carrier.
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How did you get the totals?
Deductible:
Your deductible is a flat fee amount provided by your insurance. Based on your date of care OR birth will depend on how your deductible is calculated. IF your benefits are verified and you will give birth or receive care in the same calendar year of your verification then the deductible amount is the current amount minus any monies applied OR your remaining amount. IF you will give birth OR receive care in another calendar outside of the verification year then the entire flat deductible amount will be accounted for.
Coinsurance:
This is the percentage you are responsible for along with your deductible OR without your deductible. The percentage is based on an average reimbursement of 2000.00.
Copay:
This is the flat amount you are responsible for. For Maternity you may have a one time copay and then your deductible and coinsurance cost. All other care you will normally have a single deductible.
Special Note:
*If your provider is not contracted, your provider has the right to charge you their cash fee regardless of insurance verification and insurance benefits
*If your Office Visit service is subject to a deductible, your provider has the right to accept a flat amount until an EOB is produced by your insurance that provides the exact amount to collect. -
What's Next & What to Expect
PRIOR TO YOUR BIRTH/DELIVERY $25.00
If you are interested in knowing if your midwife/provider is a covered provider and/or how your insurance will play a part in coverage/reimbursement for the care provided, this should be done prior to you delivering, BUT is NOT a required action. Please use the link below to proceed with the verification process.
https://www.favoredmedicalbilling.com/verifymybenefits.php
*IF your provider name is NOT listed, please select "MY Midwife is NOT listed"
*IF you already have your benefits, PLEASE do not complete the form attached to the above link.
AFTER YOUR DELIVERY $ 85.00
Once you have given birth and are ready to submit your claim to insurance for processing/reimbursement, please use the link below. Please note that claim submission should only be requested AFTER you have given birth OR if you have transferred care.
https://www.favoredmedicalbilling.com/ClaimSubmissions.php
*Select Midwife Services
PRIOR TO YOUR BIRTH/DELIVERY $25.00 Verification of Benefits
If you are interested in knowing if your midwife/provider is a covered provider and/or how your insurance will play a part in coverage/reimbursement for the care provided, this should be done prior to you delivering, BUT is NOT a required action. Please use the link below to proceed with the verification process.
https://www.favoredmedicalbilling.com/FMBC.php
*IF your provider name is NOT listed, please select "MY Midwife is NOT listed"
*IF you already have your benefits, PLEASE do not complete the form attached to the above link.
AFTER YOUR DELIVERY $ 170.00 Provider Only Claim
Once you have given birth and are ready to submit your claim to insurance for processing/reimbursement, please use the link below. Please note that claim submission should only be requested AFTER you have given birth OR if you have transferred care.
https://www.favoredmedicalbilling.com/FMBC.php
*Select Midwife Services
AFTER YOUR DELIVERY $ 450.00 Provider and Birth Center Facility Claim
IF you labored OR delivered at a birth center and would like to bill insurance for the time spent at the facility for a higher reimbursement than what can be received for billing the only provider, please use the link below.
https://www.favoredmedicalbilling.com/FMBC.php
*Birth Center Facility
Office/Home Visit Services & HSA /Flex Spending Account $100.00 Provider Only
For extra care such as well exams, PP care past global period, etc., claims can be submitted for the provider only to obtain reimbursement. Please use the link below.
https://www.favoredmedicalbilling.com/FMBC.php -
My insurance says they cover at 100%.
Your plan may state they reimburse at 100% / 40% / 30% etc.. , BUT at the allowed amount of your insurance plan, and not at the providers billed amount. If you would like to find out what the allowed amount is for your plan, please use the link below to do so.
http://www.favoredmedicalbilling.com/patientfaqs.php#seventeen -
Understanding the Upfront Cost Collection Process
Contract Fee
The contract fee is the set amount enforced by your insurance plan as the allowed amount (what your insurance feels the service is worth) when the provider is in network or contracted with that specific insurance plan. **There are NO contract fees for out of network or non-contracted providers
Deductible
This is a flat amounts determined by your insurance plan that the patient is responsible for prior to the insurance plan making any payments on the patient behalf
Coinsurance
The Coinsurance is a shared percentage between the patient and the insurance plan
Out of pocket
The out of pocket is a flat max amount that the patient is responsible for out of their own pocket ... the out of pocket works in a number of ways
1. The deductible and or coinsurance amount that is paid by the patient helps meet the out of pocket amount
2. The plan has neither a deductible and/or coinsurance so the out of pocket is what is collected
Helpful Hints in-network
If the contract fee is less than the deductible, then the contract fee is collected,
In the event the provider and facility is contracted IF the deductible is met by the provider collection the facility deductible is NOT collected IF after the provider fee deductible is collected but is not met then you collect the facility fee schedule amount up to the amount of the deductible
Coinsurance of the contracted fee schedule is collected in addition to the deductible amount(when there is a deductible amount)
The out of pocket is ONLY collected up to the contracted amount when there is no deductible to collect
Helpful Hints for out of network
Since there is no contract fee schedule for out of network providers, some providers will use their personal cost for services to collect the deductible and or coinsurance
In most cases in terms of reimbursement the insurance plan will use:
Medicare rates approx.. $2,300.00 (Physician Fee Schedule)
OR your insurance usual and customary (http://www.favoredmedicalbilling.com/patientfaqs.php#seventeen)
Verifications are an estimate of cost and not a guarantee of payment.
Use the link below to review how insurance process claims
http://www.favoredmedicalbilling.com/patientfaqs.php#five -
Dual Insurance Plans
Dual plans/coverage means you have 2 or more insurance plans that you are actively covered under.
It is important that you know the proper ranking or which insurance plan is primary; meaning first, secondary; meaning second and etc. This is determined by ownership policy and effective dates. Meaning any plan that you are the policy holder would be the primary plan and IF you are the policy holder for multiple plans, then the one with the eldest effective date would be primary.
It is important that each insurance plan is aware of the additional policies so proper claims processing can be done timely, this is called a Coordination of Benefits.
http://www.favoredmedicalbilling.com/InsuranceUpdate.php
Verifying Dual Plans
Verifying dual/multiple insurance plans requires the same process of verifying one. The verification form provides space for two plans to be listed for verification. Additional plans would require submission of a separate form. Depending on your provider, the cost of the verification submission may result in a fee of $25.00 per submission
https://www.favoredmedicalbilling.com/verifymybenefits.php
Billing Dual Plans
Provided services will be submitted to the primary plan for processing, which will take approximate 30 - 45 business days. Once the primary plan has properly processed the submitted claims, the claim along with the primary Explanation of Benefits will be submitted to the secondary plan for processing. Based on the accumulated benefits of the secondary policy, payment may OR may not be made. Meaning the secondary claim will be subject to any unmet deductibles, Coinsurance, or out of pocket patient responsibility of your secondary policy. -
Newborn Coverage and Financial Responsibility
New Born Coverage
Most insurance plans allow infant coverage at NO additional premium cost for the first 30 days of life. At day 31, if the child remains on the policy, additional cost may occur. The parents should confirm premium increases with their human resource department, insurance broker, etc.
ALL plans do require that the parent call in and officially ADD the infant to the policy for this coverage within the first 30 days or birth.
During that time, based on the structure of the plan, the infant will still incur patient obligation for benefits used, such as copays, deductible and out of pocket accumulation. *structure of the plan, meaning the child will be considered as an individual on the policy, and the benefits will be exact to all other members of the plan.
There are very few cases that the infant is covered under the mother’s patient responsibility; in those cases the plans will have it specifically written in their benefits booklet.
Claims/Billing
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What is the benefit of claim submission and how does it work?
The benefit of claim submission may vary for each client.
Some claims are submitted to obtain credit towards the client's deductible, coinsurance, and or out of pocket with their insurance policy for monies already paid to their provider.
Some claims are submitted for reimbursement to your provider for services rendered.
Some claims are submitted to obtain reimbursement for monies paid to your provider (reimbursement based on client/provider agreement).
Unless your provider is in network or contracted with your insurance plan there is no way to provide a reimbursement amount in which you may receive.
Providers that are out of network, claims are paid based on a calculation your insurance company has designed and is NOT shared with the provider nor FMBS.
In cases where the client has a high deductible (any amount over 5,000) little to no money is reimbursed as each deductible must be meet prior to insurance pay out.
If you are unsure of your deductible or out of cost this information can be obtained from a benefit verification. You may contact your insurance directly and request the allowed amount for CPT 59400 by calling the member service number on the back of your insurance card. -
How does the insurance determine the reimbursement/check amount?
Providers that are out of network claims are paid based on a calculation your insurance company has designed and is NOT shared with the provider nor FMBS.
Based on the average insurance allowed of $3,500 please see the example calculation below.
Insurance Allowed Amount - Deductible/Coinsurance/Copay=Payout
$3,500.00 allowed amount
$500.00 deductible
$350.00 coinsurance percent of 90/10%
$2,650.00 payout amount
The Billed Amount has NO relevance to the payout/reimbursement. The Billed amount is what WE think the care is worth. Payout/reimbursement begins at the insurance allowed amount. -
Why are the totals submitted to my insurance company different from the amount I was quoted from my provider or monies paid to my provider?
Due to auditing regulations, FMBS, as a billing company, is required to attain a set billing schedule based on national rates. These rates may differ from the provider's charging schedule FMBS represent.
FMBS billing schedule or billed charges submitted to your insurance payer does NOT mean:
Provider Maternity Care base rate begins at $8,700.00. If additional services such as labor time, lactation, etc. is provided, this will increase the amount.
Provider Infant Care base rate begins at $890.00 for initial care provided at birth, If other care is provided, it will increase the bill amount.
Facility Birth Room is billed at $9,800.00 per day for mother and $9,400.00 per day for infant.
Outpatient services performed at the facility such as IV treatment / Pap / ultrasounds / IUD placements billed at $5,000.00 to $6,000.00
That additional monies outside of what has been discussed and agreed upon with your provider are due.
Additional monies will NOT be due to your insurance company. -
How long does the claim process take?
Once FMBS has received your claim request within 24 hours (in most cases) a claim will be submitted to your insurance electronically. Your insurance will receive the claim approximate 72 hours from the time FMBS has sent your claim.
You can log onto your personal insurance account and begin to follow the claim 7 business day from the time the claim was submitted to FMBS Your insurance has by law 30 business days to fully process and release the claim from the date it is received in their system.
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When should claim request be sent?
After you have given birth is the best time to submit your claim request to ensure that billing is accurate.
If your care was provided by an out of network provider you are able to request claim submission one year from the date of care provided. -
What is billed to my insurance?
Maternity Care: Prenatal Care / Delivery / Antepartum Care / Lactation Care Infant Care: Initial exam and birth / Labs Facility/Birth Center: Use of room at the facility / Such as labor and delivery Provider Care: Office Visits provided by your physician
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How does my verification relate to reimbursement?
Your verification, depending on your provider's practice or contract signed, will determine 2 things:
Option ONE: how much you are responsible for your care
Option TWO: how much your insurance will deduct prior to releasing payment reimbursement
Option One: Your VOB will provide your plan's unmet patient responsibility broken down by Deductible/Coinsurance/Out of Pocket Max/Copay. IF your provider follows Option One, the amounts in those areas will be the amounts that you are responsible for paying upfront.
Option Two: You will pay the said amount, per your provider's contract upfront. Your reimbursement will then be calculated during the claims process using the process below. The payout amount will be your reimbursement.
Insurance Allowed Amount - Deductible/Coinsurance/Copay = Payout
$3,500.00 allowed amount
$500.00 deductible is subtracted from the allowed amount
$350.00 coinsurance percent of 90%/10% (percentage of the allowed amount)
$2,650.00 payout amount -
What are Allowed/Billed/Charges Amounts?
The CHARGE amount is the amount your provider has decided their services are worth and would like to be paid. Each provider has their own CHARGE amount and their expectation of getting paid that amount may differ. *please contact your provider directly for this amount and process.
The BILLED amount is the amount billed to the insurance company for reimbursement. FMBS uses Medicare rates and multiply those rates by 300%. The BILLED amount has NO relation to your provider's CHARGE amount and does NOT determine if additional monies are due to your provider. *Please contact your provider directly to confirm IF additional funds are due after insurance has paid.
The ALLOWED amount is the amount your insurance determines the service/care was worth. Your insurance does NOT take into consideration your provider's CHARGE amount, nor the BILLED amount. Providers that are NOT contracted do NOT have access to the ALLOWED amount so until the claim is paid your non-contracted provider does NOT know the reimbursement amount. Providers that ARE contracted are given a fee schedule which are a list of ALLOWED amounts for various services. Once the ALLOWED amount is determined, the insurance will deduct your patient's financial responsibility and then pay the claim. *All estimates for OON providers are based on a $2,000.00 ALLOWED amount.
The BILLED amount for 2016 is:
$8,700.00 for global maternity provider care (this amount is the base amount)
$9,800.00 for the facility for care provider to the mother
$4,000.00 for prenatal only
$890.00 for infant services (this amount depends on care provider)
$9,400.00 for the facility for care provider to the infant
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How much will my insurance pay?
In most cases your provider is out of network and unfortunately will NOT be able to inform you an exact reimbursement amount for services provided. Out of network reimbursement amounts are based on a usual and customary that only your insurance has privilege to. In some cases your insurance will provide the reimbursement amount to their members.
Contact your insurance provider member service department directly. Inform the insurance representative that your provider is out of network and you would like to know how much will be paid for your care.
Below are the CPT codes you will need.
59400 which includes prenatal care, delivery and postpartum care. 59426 which includes ONLY prenatal care
Once a dollar amount has been provided, minus your deductible and / or coinsurance amount from that amount and the balance will be the amount paid out. IF your deductible is higher than the dollar amount provided 0.00 will be paid out and applied to your deductible.
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My insurance should have paid more!
FMBS nor your provider can inform you the exact amount in which will be paid on your behalf to your provider or yourself as an out of network provider. The / Your insurance payer dictates the allowed amount (the amount THEY feel the claim is worth) then they / the payer begin to deduct your out of pocket cost (deductible & coinsurance) from that amount and what is left is paid. IF you feel you or your provider should have been paid more you are free to appeal the payment made to your insurance.
1. The link below is a step by step guide on how to write an appeal:
https://favoredmedicalbilling.com/forms/FMBS_Appeals_And_Recon_Guide.pdf
2. The link below is an example of a written reduce cost appeal. Please feel free to copy.
https://favoredmedicalbilling.com/forms/FAQ_Reduce_Payment_Appeal.pdf -
How does my insurance know how much I paid my provider?
When you pay your provider for care prior to your insurance being billed, the insurance does NOT know that payment exist until the claim is file.
Once the claim is filed and the claim is processed at that time the insurance determines your patient responsibility which may be more OR less than what you paid to your provider. (see FAQ #5)
In some cases your patient responsibility based on the claim processing can be more IF the claim billed charge amount is more than what you paid your provider and the case in which your patient responsibility would be less is IF the billed charge is less than what you paid your provider. (see FAQ #16)
Rather or NOT you owe additional money to your provider after the claim has processed is based on the contract you signed with your provider and you will need to contact your provider directly to confirm your account status.
Please remember that even though you may pay your provider one amount, it does NOT mean that you will be reimbursed that amount by your insurance nor may you receive full deductible credit for the amount, those amounts are determined by your insurance payer. (see FAQ #5) -
What's Next & What to Expect
PRIOR TO YOUR BIRTH/DELIVERY $25.00
If you are interested in knowing if your midwife/provider is a covered provider and/or how your insurance will play a part in coverage/reimbursement for the care provided, this should be done prior to you delivering, BUT is NOT a required action. Please use the link below to proceed with the verification process.
https://www.favoredmedicalbilling.com/verifymybenefits.php
*IF your provider name is NOT listed, please select "MY Midwife is NOT listed"
*IF you already have your benefits, PLEASE do not complete the form attached to the above link.
AFTER YOUR DELIVERY $ 85.00
Once you have given birth and are ready to submit your claim to insurance for processing/reimbursement, please use the link below. Please note that claim submission should only be requested AFTER you have given birth OR if you have transferred care.
https://www.favoredmedicalbilling.com/ClaimSubmissions.php
*Select Midwife Services
PRIOR TO YOUR BIRTH/DELIVERY $25.00 Verification of Benefits
If you are interested in knowing if your midwife/provider is a covered provider and/or how your insurance will play a part in coverage/reimbursement for the care provided, this should be done prior to you delivering, BUT is NOT a required action. Please use the link below to proceed with the verification process.
https://www.favoredmedicalbilling.com/FMBC.php
*IF your provider name is NOT listed, please select "MY Midwife is NOT listed"
*IF you already have your benefits, PLEASE do not complete the form attached to the above link.
AFTER YOUR DELIVERY $ 170.00 Provider Only Claim
Once you have given birth and are ready to submit your claim to insurance for processing/reimbursement, please use the link below. Please note that claim submission should only be requested AFTER you have given birth OR if you have transferred care.
https://www.favoredmedicalbilling.com/FMBC.php
*Select Midwife Services
AFTER YOUR DELIVERY $ 450.00 Provider and Birth Center Facility Claim
IF you labored OR delivered at a birth center and would like to bill insurance for the time spent at the facility for a higher reimbursement than what can be received for billing the only provider, please use the link below.
https://www.favoredmedicalbilling.com/FMBC.php
*Birth Center Facility
Office/Home Visit Services & HSA /Flex Spending Account $100.00 Provider Only
For extra care such as well exams, PP care past global period, etc., claims can be submitted for the provider only to obtain reimbursement. Please use the link below.
https://www.favoredmedicalbilling.com/FMBC.php -
Is It Worth Submitting A Claim?
If the provider is NOT contracted with your insurance, there is no reimbursement schedule (allowed amount) to follow which means we have no idea how much the claim will process for.
Claims are processed as follows:
Claim sent in at what we think the service is worth = billed amount.
Your insurance decides what they think the service is worth = allowed amount.
When the provider is contracted, we know what the allowed amount is and can do the necessary calculations to determine how the claim will process.
When the provider is NOT contracted, we do not have an allowed amount for the calculation.
Calculation:
Allowed amount – patient deductible – coinsurance (% of the allowed amount) = payment.
IF the deductible is higher than the allowed amount, $0.00 will be paid out and it will all apply to the deductible.
Issue with non-contracted providers, we do not know what the allowed amount is, the allowed amount may be high enough for a payout, but we would not know until the claim is processed.
Is it worth submitting a claim?
Without submitting a claim, the amount paid to your provider cannot be applied to your deductible, and maybe all the stars will align so a payment can be released. -
My insurance says they cover at 100%.
Your plan may state they reimburse at 100% / 40% / 30% etc.. , BUT at the allowed amount of your insurance plan, and not at the providers billed amount. If you would like to find out what the allowed amount is for your plan, please use the link below to do so.
http://www.favoredmedicalbilling.com/patientfaqs.php#seventeen -
Claim Filing Limits
A claim can be submitted to your insurance immediately AFTER the care is provided.
In maternity cases, it is best to wait until the baby is delivered before filling a claim.
IF you transferred from one provider to the other, you can bill services for the 1st provider as soon as you begin care with the 2nd provider.
Claims filling limits below: You have up until the below time frame from the date of care (For maternity, infant date of birth) to submit your claim to insurance.
365 days from the date of care
Aetna
Blue Cross Plans
Cigna
Humana
United Health Care
120 days from the date of care
Health Net
90 days from the date of care
Medicaid Plans -
Connect with Your Insurance
Claim Status Check
Thank you for your inquiry regarding your submitted claim. Because your insurance requests 30 business days to process your claim, Favored Medical does not provide claim status prior to 30 business days of submission. You are welcome to use the link below to create an account directly with your insurance plan to track your claim process or you may contact your member service department using the phone number from the back of your insurance card.
United Health Care Member Account
Cigna Health Care Member Account
Health Net Care Member Account
Humana Health Care Member Account
Blue Cross Blue Shield of Arizona
Anthem Blue Cross & Blue Shield
Claims process:
1. Your claim is submitted within 48 hours of receipt to Favored Medical Billing to your insurance plan.
2. Your claim is received and logged with a claim number by your insurance provider within the first 7 business days of receipt.
3. Your claim is then "worked" for processing .. 30 business days later
4. Your claim is processed, either with payment or towards your deductible
5. Paid claims take an additional 10 business days for a check to be released and mailed.
6. Please allow proper mail/delivery time At 31 business days
If you have not received any correspondence from your insurance and do not see your claim on file (if being tracked), please contact Favored Medical Billing for proper follow up. -
Usual & Customary Medicare Rates
For out of network providers, there is no fee schedule, so most insurance companies will state services are covered at usual and customary rates which are Medicare rates.
Description of Usual & Customary
https://en.wikipedia.org/wiki/Usual,_customary_and_reasonable
https://www.healthcare.gov/glossary/UCR-usual-customary-and-reasonable/
You can view the Medicare fee schedule to estimate your U & C.
Click the link: https://www.cms.gov/apps/physician-fee-schedule/overview.aspx Click "Start Search" next to the computer icon "Accept" the disclaimer at the bottom of the page Leave all the default selections HCPC CODE 99204 new patient office visit 59426 prenatal care 59400 prenatal care/ delivery/ postpartum care Modifier choose "all modifiers" Submit
The page will load:
First row, 4th column (non-facility price). This is the U & C to use as the insurance allowed amount.
This is just an estimated process. Since the provider is NOT contracted, there is no guaranteed amount of the U & C or allowed amount. -
Bill Charge Amounts
To calculate billed charge amounts, I use Medicare rates times 400%
Provider
Mother Global Maternity
59400 - $8,700.00
59426 & 59425 - $4,000.00
** the above are base rate charges and does NOT include med, additional time, etc…
Infant initial care
99460/99464 - $860.00
** the above are base rate charges and does NOT include med, additional time, etc…
Facility
Mother Facility - $9,800.00
Infant Facility - $9,400.00
Education & Hearing - $1,000.00
IUD & other Outpt - $9,600.00
Ultrasounds - 3000.00 -
Global VS Itemized Billing
Global Billing - billing done after delivery
Prenatal, Delivery, and PP Care = $2,950.00
Itemized Billing - billing done during care (several options)
Prenatal Only Package 6+ visits = $840.00 Delivery Only = $1,050.00 Approximate Total= $1,890.00
Prenatal Only Package 4-6 visits = $525.00 Delivery Only = $1,050.00 Approximate Total = $1,575.00
Single Prenatal Visits by date = $86.00 (15 OR multiply by however many visits seen) Delivery Only = $1,050.00 Approximate Total = $2,340.00
*These are estimates of reimbursement
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Claims not submitted to Insurance
During the course of your Maternity care, there will be very little claims that will process through your insurance plan at until the end (delivery or transfer). The visits processed during your pregnancy will be the visit that confirms your pregnancy and any care provided outside of the normal prenatal visit. Based on your need of care, there may be only one or two visits until the delivery. After your delivery, the big claim(s) will be submitted as your provider bills globally for Maternity. Those billing may include the provider and facility claims for Mom and Baby.
Please review the other links listed below and in the the event you have additional questions, please schedule a time to speak.
Links to Review
http://www.favoredmedicalbilling.com/patientfaqs.php#thirteen
http://www.favoredmedicalbilling.com/patientfaqs.php#twentyone
http://www.favoredmedicalbilling.com/patientfaqs.php#twentyeight
http://www.favoredmedicalbilling.com/patientfaqs.php#thirtyseven
Schedule an Appointment:
http://www.favoredmedicalbilling.com/conferencecall.php -
Insurance Types and Plans
A type of insurance coverage that pays for medical and surgical expenses that are incurred by the insured. Health insurance can either reimburse the insured for expenses incurred from illness or injury or pay the care provider directly. Health insurance is often included in employer benefit packages as a means of enticing quality employees which is a GROUP policy or privately purchased by the individual which is called an INDIVIDUAL policy.
Types of Insurance
Group Policy
Policy obtained by typically through an employer
Health insurance is often included in employer benefit package A portion of the premium may be shared between the employer and the employee
Individual Policy
Policy obtained on your own, without being connected to an employer or group
privately purchased premium is paid only by the individual who obtains the policy and is paid directly to insurance company
Medicaid Policy
Medical plans provided and funded by your residential state (google "state Medicaid plan for your specific state) Enrollment is based on income, and or disability
Medicare Policy
Medical plan provided and funded by your federal government to all states Enrollment is based on age, and or disability Medicare is broken into four benefit sections in which care is covered: Part A: Hospital, skilled nursing facilities, hospice, nursing homes, and home health visits Part B: lab tests, surgeries, and doctor visits and supplies, DME benefit like wheelchairs and walkers Part C: Option to choose a Medicare Advantage Plan Part D: This portion covers medication/ pharmacy benefit
Medicare Advantage Plan
A commercial version of the Medicare plan and offer the same Medicare benefits Type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans
VA Benefit
Medical coverage offered for veterans, for VA providers only it is not an actual medical plan but a benefit for services
Commercial Policy
Commercial health insurance is defined as any type of health benefit not obtained from Medicare or Medicaid The insurance may be employer-sponsored or privately purchased Commercial health insurance may be provided on a fee-for-service basis or through a managed care plan
Examples of Commercial Plan
Blue Cross Blue Shield Cigna United Health Care
HMO
Health Maintenance Organization An HMO delivers health services through a network The least freedom to choose your health care providers because you must stay in-network An assigned primary care physician to manage your care and refer you to specialists when needed to ensure coverage by the health plan
PPO
Preferred Provider Organization A moderate amount of freedom to choose your health care providers -- more than an HMO because you are NOT obligated to stay within the network Higher premium out-of-pocket costs than an HMO The ability to manage your own health care You can see out-of-network doctors
POS
Point-of-Service Plan A POS plan blends features of an HMO with a PPO More freedom to choose your health care providers In some cases your out of pocket is lower when you stay within your network oppose to utilizing your PPO benefit A primary care physician who coordinates your care when you use network providers or The ability to manage your own health care if you choose a non-contracted provider
HDHP
High-Deductible Health Plan One of these types of health plans: HMO, PPO, or POS but has a unusually higher deductible than regular plans Lower monthly premiums but more out of pocket cost for care
HSA
A type of savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses. A Health Savings Account can be used only if you have a High Deductible Health Plan (HDHP). High-deductible plans usually have lower monthly premiums than plans with lower deductibles. By using the untaxed funds in an HSA to pay for expenses before you reach your deductible and other out-of-pocket costs like copayments, you reduce your overall health care costs.
What is My Insurance Card telling me?
Most insurance card will provide the following information, and ALL of it is very crucial to the proper handling of your claim and billing submissions.
Front of the card Patient Name ID Number Type of Plan (PPO, HMO, POS) Co-pay amount and sometimes deductible Back of the card: Member phone service number Provider phone service number Where to send claims for processing
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Dual Insurance Plans
Dual plans/coverage means you have 2 or more insurance plans that you are actively covered under.
It is important that you know the proper ranking or which insurance plan is primary; meaning first, secondary; meaning second and etc. This is determined by ownership policy and effective dates. Meaning any plan that you are the policy holder would be the primary plan and IF you are the policy holder for multiple plans, then the one with the eldest effective date would be primary.
It is important that each insurance plan is aware of the additional policies so proper claims processing can be done timely, this is called a Coordination of Benefits.
http://www.favoredmedicalbilling.com/InsuranceUpdate.php
Verifying Dual Plans
Verifying dual/multiple insurance plans requires the same process of verifying one. The verification form provides space for two plans to be listed for verification. Additional plans would require submission of a separate form. Depending on your provider, the cost of the verification submission may result in a fee of $25.00 per submission
https://www.favoredmedicalbilling.com/verifymybenefits.php
Billing Dual Plans
Provided services will be submitted to the primary plan for processing, which will take approximate 30 - 45 business days. Once the primary plan has properly processed the submitted claims, the claim along with the primary Explanation of Benefits will be submitted to the secondary plan for processing. Based on the accumulated benefits of the secondary policy, payment may OR may not be made. Meaning the secondary claim will be subject to any unmet deductibles, Coinsurance, or out of pocket patient responsibility of your secondary policy. -
Medical Liens
Dear Patient,
You may have received a copy of the medical lien filed by Dr. Mussman PLLC.
The medical lien was filed because your care meet the criteria of one of the following:
You were treated due to an accident that may result in a financial settlement Your insurance plan is Blue Cross Blue Shield and payments for the care received by Dr. Mussman will be mailed to you. Medical liens are not permanent and are easily removed.
In order to have your medical lien removed, one of the following MUST occur:
Care provided by Dr. Mussman MUST be paid off in full as part of any settlement monies. Any and ALL payments received by you/or plan policy holder MUST be signed over to Dr. Mussman PLLC. Once the above has been resolved, your account will be released of the medical lien. This process is completed within seven business days.
For additional questions, please contact the billing office @ 623.322.0730.
Please see the below instructions on how to properly sign over received insurance payments.
Sign Over Checks
In the event the provider is considered Out of Network, the insurance may process the claim and release the funds to patient directly INSTEAD of your provider in error. Please use the following steps to properly sign over payment.
When Patient Receives the Check that is Payable to the Provider: On the back of the check write: "Pay to the order of YOUR PROVIDER NAME" and mail or walk-in the payment to the office.
Office Address: 10240 W Indian School Rd suite 115, Phoenix, AZ 85037
Option Two: Contact the Office Manager for Dr. Mussman PLLC to arrange direct courier pick up.
Heather @ 623.243.9077, state you have received an insurance check and would like to arrange a pick up. -
New Provider Claim Processing Delay
Although your claims has been submitted by FMBS, it has been rejected/NOT received by your insurance plan. The rejection reason is due to your providers registration to submit claims to your insurance plan.
We have already notified your provider of the needed registration and is currently waiting for the returned application/update form.
Once the form is received, we will send it to the provider relations department of your insurance to have your provider added to the plan roaster. This process will take 30 business days.
Once the provider is added, we will then re-submit your claim to your insurance plan for processing.
Details regarding how the claim process from can be found at the link below.
https://favoredmedicalbilling.com/patientfaqs.php
Please note that holidays may affect the above listed time-lines.
Payments
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Why am I NOT getting a refund?
Refunds are based on the verbal or written agreement between you and your provider of care. FBMS is unable to dictate rather a refund is due. In most cases providers require that refund requests are initiated AFTER all care has been provided or the baby has been delivered in reference to maternity care. Once All care has been provided and your insurance plan has processed all the claims, it is at this time you can make a refund request.
The process is as follows;
Claim(s) billed and processed by your insurance plan will produce the amount that your insurance has deemed patient responsibility.
The provider will subtract any amount that has been previously paid on your account from the amount your insurance plan has deemed your responsibility.
Based on the remaining amount, you will be refunded any overage you have paid your provider OR invoiced any deficit amount. -
Why do I still owe my provider even when my insurance has paid?
Shared Cost Model: If your providers practice is based on a "shared cost" model your provider can request monies from you that may or may not coincide with your insurance benefits to share in the cost of their charge amount. When you deliver, and a claim is submitted to your insurance provider the expectation is that your insurance provider will pick up the remaining amount to meet your providers "shared cost" charge amount. Depending on the amount collected or deficiency in collection, and the agreement between you and your provider you may still have monies due for the care provided.
Balance Billing Model: If your provider is out of network/non-contracted any monies paid to your provider by your insurance company in addition to monies paid by the client, your provider reserve the right to collect up to the billed charge amount listed on the claim for services rendered. -
What if I need to make a payment?
Most providers ONLY accept payments directly at their facility in which you will need to continue to make payments in that manner.
If you are a client of: Blossom Birth or Women's Birth and Wellness Center, FMBS can accept payments via phone or email or web.
Payment Arrangement Agreement
More
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Is my information safe?
Because FMBS Is HIPPA compliant all information transported electronically is sent and received through a secure format.
All faxes and phone messages require a password only the owner of FMBS has access to -
What if I Transfer Care?
Maternity Patient:
If you transfer care to either another provider while still pregnant or to the hospital during labor, your services up until the transfer can be billed to the insurance. IF you received an estimate of financial responsibilities, the transfer will effect that estimate drastically. The goal is to bill the Global Maternity Care; care that include the prenatal, the delivery, and postpartum care. Billing globally gives the highest reimbursement as the service includes everything. When you are transfer we can no longer bill globally and must only bill for the services provided which is reimbursed much lower. A transfer may cause additional financial responsibility, please contact your provider directly to inquire.
All Patients:
If you transfer care, depending on if your new provider is contracted or not, you can become financially responsibility for additional cost. It is best to confirm what network status the new provider is prior to transferring
How it is billed:
The provider that provides at ONE prenatal visit AND delivers the baby is allowed to bill the global billing which includes prenatal / delivery / PP care.
The provider that you received prenatal care from but DID NOT deliver the baby can ONLY bill the prenatal package and PP care.
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Midwife VS Hospital
I recently had the pleasure of viewing a hospital bill for a vaginal delivery in the hospital and WOW! I was first shocked to see that the hospital bills for EVERYTHING, like aspirin, yes Bayer aspirin, has a pricey tag of 17.00! Overall, the hospital bill for a 24 hour stay was 8,000.00. This did NOT include the bill from the OBGYN that delivered the baby, the anesthesiologist, and finally, the doctors that made rounds. This quickly added an additional 5,000.00. The total cost was 13,000.00.
IF the hospital and provider were all contracted/in-network, the out of pocket cost of care ranges about 3,000.00 to 5,000.00 depending on the plan deductible.
See the example below:
Deductible - this amount is due before insurance pays anything to anyone, whether contracted or non-contracted
Then, Coinsurance - this percent is shared between patient and insurance after the deductible has been met
Hospital:
Total amount 13,000.00 contracted rate 7,000.00
Deductible 3,000.00
Coinsurance 30% of 7,000.00 - 2,100.00
Total Amount due to Hospital 5,100.00 -
Why should I pay you?
The service of verifying your benefits and/or submitting a claim on your behalf are all optional services. You are in no way obligated to pay Favored for those services. You can accomplish both verifying your benefits/ submitting claim by contacting your member service department number located on the back of your insurance card.
The benefit of Favored handling these 2 services; provides one less thing for your to do and the understanding of what questions need to be asked for the best success of coverage and processing of claims.
Verifying Benefits:
Knowing rather or not your provider is covered and at what benefit level sooner rather than later allows you to decide rather of not you want to move forward with the additional fee of 85.00 to submit a claim along with a better understanding of the financial benefit of submitting a claim
Claims Submission:
Most providers do not handle billing in any capacity and the invoices they provide usually are not equipped with the necessary CPT/DX codes required by your insurance plan for proper processing.
Dealing with insurance can be both time consuming and frustrating which is why we offer these services. Again, these services are optional. Please understand for liability reasons Favored does not follow up or take over requests that were NOT initiated by our company. -
Why do I need to pay for coding?
Favored Medical Billing (FMBS) is a billing company that is sustained by providing medical coding and billing services. Because of this, we are unable to provide these services for free. I understand that this can be frustrating, as you may have already paid your provider for care, but your current provider has outsourced all billing needs.
Favored Medical does offer two options:
Option 1: $85.00
FMBS can code the care that was provided to you
Submit the care on proper medical CMS 1500 HCFA claim form
Provide follow up with insurance until the claim has been properly processed.
To move forward with this option, please use the link below:
https://www.favoredmedicalbilling.com/ClaimSubmissions.php
Option 2: 60.00
For a discounted rate, FMBS will provide you the proper codes and description for care that you may have received which you can then select which one best fits the care received, so you may and submit your claim directly.
To move forward with this option, please use the link below:
Disclaimer: Patient direct code selection and/or claim submission is NOT the responsibility of Favored Medical Billing. In the event your claim is denied/rejected, Favored Medical Billing will charge its full fee to assist and correct for proper submission. Favored Medical Billing reserves the right NOT to assist in patient direct claim submission. -
Unplanned hospital transfer
I am sorry to hear of your transfer.
The care you received by the provider/midwife and your stay, whether laboring or delivery at the birth center facility, will be billed to the insurance. Based on what your insurance informs us via the EOB of patient responsibility; such as deductible/coinsurance/copay, you will be invoiced to pay that amount minus any monies you have paid upfront. In the event there is an overpayment from what you may have paid upfront and what your insurance states you are responsible for, a refund will be due to you.
Claims received from your provider to FMBS are billed to the insurance within 3 business days of receipt. We are unable to ensure that our claims will be received and processed before the hospital submits their claims. In most cases, our claims are processed first, but that can change case by case, as your insurance plan can request records and other information that will delay the process of our claims verses the hospital claim submission.
Helpful Things:
Contact your provider and confirm that they have submitted your claim to FMBS
Gather receipts of amounts you have paid to your provider thus far
Register online with your insurance plan so you can easily track and follow your claims
In the event you feel a refund is due, please use the link below to make your request
https://www.favoredmedicalbilling.com/Refund.php -
Oh My Email!
We understand that remembering all the emails associated with Favored Medical Billing is hassle and we do senecrely apologize. It is still very important that inforamation is sent to the right department so the right person can handle request in a timely manner.
We have found it helpful to create contacts to identify where what goes.
Info@favoredmedicalbilling.com
Kashuna email
Benefits@favoredmedicalbilling.com
Questions regarding VOBs and Auths
Superbills@favoredmedicalbilling.com
Where claim form and corrections to claim forms are handled
Claims@favoredmedicalbilling.com
Claim status and followup concerns are addressed here
r-r8fd6937509146bdb@mail.sharefile.com
Sharefile the secure server to receive ALL insurance corespondance, payments and denials
We appreciate your assistance in this matter.
