FAQs – Insurance

FAQs ( Frequently Asked Questions )

Insurance Questions

Who is the “guarantor”?

The guarantor is the person legally responsible for all charges incurred by the patient. If the patient is over the age of 18, then they are listed as their own guarantor. Exceptions would include:

Full-time high school/college students covered under their parents insurance. If parents are divorced or separated, the custodial parent is the guarantor. If the custody is equally shared, the parent who has the insurance coverage on the patient is the guarantor.
If a patient is mentally or physically challenged, and resides with a parent or legal guardian, the parent or legal guardian is the guarantor. If the patient lives in a group home, the patient is his/her own guarantor.

If the patient is under the age of 18, the guarantor is determined as follows:

If both parents are married to each other and live at the same residence, the primary policyholder is listed as the guarantor. If there is no insurance coverage, the father would be the guarantor.
If parents are divorced or separated, the custodial parent is the guarantor. If custody is equally shared, the parent who has the insurance coverage on the child is the guarantor.

The following applies to emancipated minors, then the patient/minor is their own guarantor:

An individual who fathered a child.
An individual whose mother gave birth to a child.
An individual who has a court ordered document indicating that the patient/minor is emancipated.

What is the difference between “coinsurance” and “copayment”?

A copayment is a required payment by the insured to pay a set or fixed dollar amount (i.e. $35, $50, etc.) each time a particular medical service is provided. Coinsurance is the portion of medical costs that are shared by both the insured (the patient) and the insurer.

What does “coinsurance” mean?

Coinsurance is a form of cost sharing. After your deductible has been met, your insurance plan will begin paying a percentage of your medical bills. The remaining amount, known as coinsurance, is the portion due from the patient

What does “deductible” mean?

The deductible is a provision in many insurance policies that requires the insured to incur a specific amount of medical costs before insurance benefits are provided. For example, if a member’s policy contains a $500 deductible, the member must accumulate and pay $500 out-of-pocket before the insurance carrier will begin to pay benefits. Once the patient has met the deductible, the carrier usually pays a percentage of the bill.

What does “copayment” mean?

A copayment is a predetermined fee the member pays to providers. Copayments are applied to emergency room visits, hospital admissions, outpatient visits, office visits, etc. The copayments are determined by your insurance plan and the cost is usually minimal. Patients should be aware of the copayment required prior to receiving healthcare services.

What is HIPAA?

For information about the Health Insurance Portability and Accountability Act (HIPAA), please see http://www.hhs.gov/ocr/privacy

If the physician group does not participate with my insurance carrier, why am I being billed for the balance?

If you disagree with the insurance company’s payment amount, contact the insurance company immediately and ask them to review how the claim was processed. If the insurance company finds that and error was made, note the information and with whom you spoke with at the insurance company. Request an anticipated payment date and ask if they need anything from you. If the insurance company feels the bill was paid correctly and you still disagree, find out from the insurance company what you need to do to file an “appeal” with them. Filing an appeal will not guarantee that the insurance company will pay more on your bill, but the claim will be reviewed for reconsideration. ProBill also offers various ways of helping you pay your bill such as payment plans or discounts for paying in full.

If the hospital is participating with my insurance, why are the doctors not in network?

Your hospital has chosen to partner with an independent emergency room provider group to provide administrative and staffing services. Because the emergency room physician group is not employed by the hospital, the list of participating insurance plans may be different.

How do I know that you are billing me the correct amount?

Once your insurance carrier pays their portion of the bill, they will send you an Explanation of Benefits (EOB) to show how the claim was paid. You can compare your EOB to the statement sent by ProBill. How the carrier paid the claims is based on their contract with the physician group, if applicable, and their contract with you. If you feel the insurance company should have paid a higher amount, please contact them directly for resolution.

What if I receive a denial due to a Coordination of Benefits?

If an insurance carrier denies your claim due to a COB (Coordination of Benefits) please contact your insurance carrier immediately. If your insurance carrier sent information to your home requesting additional information necessary for them to process and pay your claim please contact them in order to avoid total financial responsibility for your unpaid claim.

Why did my insurance carrier send me the check for the physician services instead of sending it directly to you?

Some insurance plans require that the patient or policy-holder receive payment, and then the policy-holder will pay the physician. If you have received an insurance payment for your emergency room physician services, please forward the payment along with your Explanation of Benefits (EOB) to ProBill or contact our Patient Services Department at 800-998-7578 (Monday – Thursday 7:30am – 5pm EST and Friday 7:30am – 4pm EST).

I just received a bill which shows that my insurance didn’t pay any of my charges. Could you please re-bill my insurance?

We cannot re-bill if the insurance has previously denied the claim. The insurance company will process the claim as a duplicate. If you feel that your insurance denied the charges in error, please call your insurance company. As a consumer, you always have the right to appeal a decision from your insurance company. Contact your insurance company to learn about their appeal process.

I gave my insurance information to the hospital. Why am I receiving a statement?

If ProBill has received your health insurance information from the hospital, we will bill the insurance company first. If for some reason ProBill did not receive the insurance information, it is important for you to call and make sure our records are up-to-date. Therefore, simply reviewing your health insurance information with a Patient Services Representative, or emailing this information to ProBill, enables us to bill or re-bill your insurance on your behalf and remove your invoice from a past-due account status.