Insurance Hints

Insurance Hints you may find helpful and remember you can always use EAP Counseling Services from your employer. Call HR and find out about your free confidential services.

Schedule-Now-ButtonAlthough Family Counseling San Diego (AKA FamilyCounselingSanDiego.com) or Director, W Patrick Martin, MA, LMFT whom is on multiple insurance panels that is not an assurance of your insurance paying or that we know what your EOB (Explanation of Benefits) includes coverage with your insurance that is your responsibility. If we state we will take your insurance for example, you tell us that you have a PPO that does not insure payment to us or yourself. We do take all PPOs but recently found an exclusion with Anthem and no longer will take any Anthem insurance. We sometimes deal directly with insurance providers, we are happy to provide you with some helpful hints regarding your insurance but have spent hours attempting to come to an agreement with some insurance carriers but they refuse to provide direct phone numbers or ways to address billing issues that arise at times. With Anthem specifically we have sent there Behavioral Health Provider email which is all they provide us as a way to contact them without any response after there costumer service representative assured us they would response within 2-3 business days which we have attempted multiple times for Anthem which is why we refuse to deal with them further. Please complain to them to allow your provider to be on there panels as there is few people whom has the specialized trained staff that we have.

We are a direct payment practice: this means that you pay us for each visit at the time of service, and we provide you with an itemized statement that you may choose to submit to your insurance provider. This statement is what most insurance providers request in order to respond to your claim. It is important that you attach it to your insurance claim form and mail it to your provider for reimbursement.

If we try to help you with your insurance provider; hence, we bill your insurance and take just the co-payment, we strongly recommend that you clarify ahead of time what type of coverage with your insurance you have for mental health services (Psychiatry, Medication Management, Psychotherapy, and Group Therapy). Coverage can change; you will want to know this ahead of time.

1. Out of Network benefits: we are considered an Out of Network provider for some insurances. Ask about the deductible, percentage of coverage for each visit, maximum number of visits covered yearly and lifetime for OON providers. Does your insurance year start in January: not all do.

2. InNetwork benefits: FamilyCounselingSanDiego.com with Walter Patrick Martin, MA, LMFT has joined Tricare West, UHC Military, Optum Health Military, Medi-Cal San Diego, Aenta, Beacon, Humana, Bluecross of California.

3. Is PreAuthorization or PreCertification required in order to start services? If so, who calls to request it? If Preauthorization/Precertification is required, and you do not comply, you are doing so at the risk of losing all reimbursement for treatment. So please call your insurance requesting PreAuthorization if you are unsure.

4. R&C: This is the “reasonable and customary” price of each service. Insurance providers determine the price for each treatment service according to their own system. Different insurance providers pay different R&Cs. Keep in mind that the R&C amount your provider has set may not necessarily match our fee schedule. If you do receive reimbursement from your insurance provider, realize that you will be receiving benefits based on the particular percentage of their R&C your provider sets, not ours.

5. Ask for the specific payer code # and address to send your claims as some insurance companies have multiple address and multiple payer code numbers. Is a special form needed to complete claims? How long will you be waiting for reimbursement? We suggest keeping a separate binder for all of your insurance provider documents.

We hope this is helpful.

Janet Phillips, LCSW

Walter Pat Martin, LMFT