Billing & Insurance FAQs

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ABOUT FRACTURE AND SURGERY CHARGES

CPT Codes

Physicians bill using CPT codes. Physicians are REQUIRED to bill according to the CPT guidelines divided into categories:

• Evaluation and Management which covers office, ER or inpatient exams, histories, review of imaging and outside notes.

• GLOBAL Codes which include treatment of fractures, surgery, injections and other office procedures. This is a bundle package good for 10-90 days of visits. Follow up visits are free within this time. Fractures and Surgeries are global CPT codes. THESE CODES GO TO YOUR DEDUCTIBLE. Included in this package is: treatment of fracture or surgery, 90 days of office follow up visits and the first application of splint or cast.

INSURANCE COMPANIES LIST ALL GLOBAL CODES AS “SURGERY” EVEN IF THE CODE IS FOR A NON-DISPLACED FRACTURE IN THE OFFICE SETTING, AND NOTHING CLOSE TO SURGERY OCCURS.

NOT INCLUDED IN THE GLOBAL PACKAGE:

• Subsequent cast changes – slings – splints – braces- cast supplies

• X-rays

• Treatment not related to the original fracture or surgery

The contracted fee is the “Allowable fee” that you and your insurance company are responsible for.

We hope this helps you understand your EOB (Explanation of Benefits) from your insurance company and our bill based on the EOB from your insurance company.

If you have questions, call your insurance company, and/or our billing company at (520) 529-5526.            We outsource our billing.

Deductible

The deductible is the amount you pay before insurance pays. Deductibles restart January 1st. Some plans pay doctor visits without meeting the deductible first.

Co-insurance

One common co-insurance split is 80/20. The insurance company will pay 80%, and you pay 20%. After the deductible is met, you are responsible for 20% of the bill.

Co-payments

The co-payment is amount due at time of service. We charge the amount our eligibility software shows us. It may be wrong, in which case we will bill you the difference or refund you.

CONTRACTED INSURANCE COMPANIES

Effective January 1st, 2012 our office requires courtesy referrals for ALL insurances policies.

WE ARE A SPECIALIST OFFICE. ALL HMO PRIVATE PLANS AND AHCCCS PLANS REQUIRE A REFERRAL FROM A PCP FAXED TO 520-296-9683.

  • ACPN ( America’s Choice Provider Network)

  • AETNA

  • Ambetter

  • Arizona Complete Healthcare (AHCCCS) (with referral from PCP)

  • BANNER HEALTH (In-Network)

  • Banner UNIVERSITY FAMILY CARE ( AHCCCS) (with referral from PCP)

  • BLUE CROSS BLUE SHIELDwithCERTAIN GROUP NUMBERS 

  • CIGNA (HMO plans require referral from PCP) (Open Access or PPO - no referrals required)

  • EQUALITY HEALTH NETWORK

  • FIRST HEALTH/COVENTRY/CNN

  • FORTIFIED PROVIDER NETWORK

  • Fusion Network

  • GEHA

  • GOLDEN RULE

  • GREATWEST

  • Steward/Health Choice ( AHCCCS) (requires referral from PCP)

  • HUMANA (HMO plans require referral from PCP)

  • Indian Health Services with AHCCCS (Requires dated referral from IHS)

  • Liberty Healthshare

  • MARKETPLACE PLANS (Some require PCP electronic referrals through insurance website)

  • Medi-Share (we accept, but are considered “out of network”)

  • Mercy Care (AHCCCS and Foster)- no referral required

  • Network of America

  • PNOA Provider

  • Sanar

  • TRICARE (Prime plan requires prior authorization from PCM)

  • UNITED HEALTH CARE – all plans including Community Care (AHCCCS)

  • All Savers through UHC Choice Plus

  • UNITED MEDICAL RESOURCES (UMR) 

  • Banner UNIVERSITY FAMILY CARE ( AHCCCS) (Requires referral from PCP)

    We do accept “out of network” authorizations for private companies we are not contracted with. Please call our office to obtain CPT codes patient will need for you to obtain the auth. Also, we accept self-pay patients. All non-contracted patients will be required to pay in full at time of appointment, and we will courtesy bill for them and refund the deposit.

BLUE CROSS BLUE SHIELD Third Party Payors:

  • AmeriBen Solutions, Inc.

  • Employee Benefits Administration

  • Fringe Benefit Services, Inc.

  • Gilsbar, L.L.C.

  • Health Now Administrative Services

  • Health Smart Benefit Solutions

  • Mayo Management Services, Inc.

  • Meritain Health, Inc.

  • Mountain States Administrative Services, Inc.

  • Pinnacle Claims Management, Inc.

  • Southwest Service Administrators, Inc.

  • Summit Administration Services, Inc.

  • Tall Tree Administrators

  • Web – TPA, Inc.

  • Zenith American Solutions

CIGNA Third Party Payors:

  • Southwest Service Administrators, Inc.

ACPN Third party providers:

             AZ plans: 

  • Alpha Vision Insurance

  • Ameriprise

  • Arizona Metropolitan trust

  • Continued AZ plans for ACPN:

  • Arizona Metropolitan Trust

  • Arizona Pipe trades Health and Welfare Fund

  • Assured Benefits Administrators

  • Basha’s Risk Management

  • Compstar Systems

  • IBEW 640

  • Insurers Admin Corp

  • Plumbers Local 8

  • Plumbers Local 88

  • ProCentury Company

  • Quik Trip Corporation

  • Republic Group

  • Salt River

  • Secura Insurance Company

  • Southwest Service administrators

  • Summit SRT Administrators

  • UFCW Employer Plan

  • Union Standard Insurance Group

  • Western Growers Assurance Trust

National Plans:

  • AHH

  • AIG

  • AIM Benefit Services

  • ALTRUA

  • Ameriplan

And many more. Please call our office or look on the ACPN website for details.

We do accept “out of network” authorizations for private companies we are not contracted with. Please call our office to obtain CPT codes patient will need for you to obtain the auth. Also, we accept self-pay patients. All non-contracted patients will be required to pay in full at time of appointment, and we will courtesy bill for them and refund the deposit.