Your Quick Guide to Insurance
Navigating your insurance plan can be overwhelming, whether you have Medi-Cal or another type of insurance. This guide will help you understand your coverage, recognize different insurance names, and differentiate between medical and behavioral health benefits. We’ll also cover why secondary insurance cannot always be billed directly and the most common reasons for claims denial.
What is Medi-Cal?
Medi-Cal, California’s Medicaid program, provides health care services to individuals with low income. Coverage can include:
- Straight Medi-Cal: Managed directly by the state, where providers are paid per service.
- Medi-Cal Managed Care Plans: Private companies providing care with their own networks. Common names include:
- L.A. Care Health Plan (formerly Beacon, now Carelon)
- Anthem Blue Cross (also known as Anthem Medi-Cal)
- Kaiser Permanente
- Health Net (also known as MHN)
- Molina
- Blue Shield Promise of California
- IEHP
- CalOptima
HMO vs. PPO Plans
HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) are common plan types:
- HMO Plans: Require choosing a primary care physician (PCP) and getting referrals for specialists. They often have lower out-of-pocket costs but less provider flexibility.
- PPO Plans: Offer more flexibility in choosing providers and do not require referrals but may have higher out-of-pocket costs.
Behavioral Health vs. Medical Benefits
Behavioral health benefits (mental health and substance use services) can be managed separately from general medical benefits:
- Behavioral Health Services: Sometimes managed through separate networks. If you are uncertain if your behavioral health benefits carve out to another network, you can call the Behavioral Health benefits number located on the back of your card to request this information. Some plans may also require distinct insurance authorizations.
- Medical Services: General medical care, including doctor visits and hospital stays, is usually covered by your primary insurance plan.
Why We Can’t Bill Secondary Insurance Directly
Billing secondary insurance directly can be complex for several reasons:
• Billing Procedures: Insurance providers typically require that the primary insurance processes the claims first. This is necessary to determine what (if any) cost the secondary insurance should cover. We cannot bill secondary insurance directly because each plan needs to see how much the primary insurance has paid before processing any remaining balance. If the primary insurance does not cover a service, the secondary will not cover either.
• Claims Processing: We submit claims to the primary insurance first. After the primary insurance has paid, we can then submit any remaining balance to the secondary insurance, however, it is not a guarantee secondary coverage will pick up remaining costs. This process ensures accurate payment and prevents errors in claims processing.
Most Common Reasons for Claims Denial
Understanding why a claim might be denied can help you avoid issues and address them quickly. Common reasons for claims denial include:
- Incorrect Information: Errors such as misspelled names, incorrect dates of service, or wrong insurance ID numbers can lead to denials.
- Lack of Authorization: Some services require prior authorization. If this is missing or incorrect, the claim may be denied.
- Out-of-Network Providers: Services received from providers outside your insurance network may not be covered, leading to denials.
- Eligibility Issues: Claims may be denied if the patient’s insurance coverage was not active on the date of service or if eligibility requirements were not met.
- Duplicate Claims: Submitting the same claim more than once can resultin a denial.
- Non-Covered Services: Certain services or procedures may not be
covered under your plan, leading to denial of the claim. - Failure to Meet Policy Guidelines: Claims not meeting specific policy guidelines or benefits limits may be denied.
How to Identify Your Plan
• Check Your Card: Look for the insurance company name or network on your card. Behavioral health benefits might be managed separately.
• Review Welcome Packet: This document will detail your plan and coverage, including HMO or PPO structures.
• Contact Customer Service: For questions about your coverage, including HMO vs. PPO details, behavioral health services, COB, or claims denial reasons, reach out to your insurance provider directly.
Tips for Managing Your Plan
· Know Your Benefits: Understand what’s covered under both your medical and behavioral health benefits.
· Use Network Providers: To avoid extra costs, choose doctors and specialists within your plan’s network.
· Track Referrals and Authorizations: Ensure all necessary referrals or authorizations are completed, especially for specialized services.
· Manage COB (Coordination of Benefits): Report any additional insurance to ensure proper coordination and coverage.
· Address Denials Quickly: Review denial reasons, correct any errors, and follow up with your insurance provider to resolve issues.
By understanding these basics, you can better manage your insurance benefits and ensure you receive the care you need. If you have questions or need assistance, don’t hesitate to contact your insurance provider or our office. We’re here to help!
“Insurances can be complicated, but we are here to help! Make sure to tell your providers about changes to your insurance as soon as possible, so that we can make sure you are covered and aware of your responsibility. One common misconception we see is when patients have multiple insurances, they sometimes choose only one insurance to give us. Unfortunately, patients aren’t able to pick which insurance they want to use, as there are strict rules that insurances must follow to determine who is the primary insurance. It is very important to provide our team with all insurance plans, so we can ensure the correct insurance is billed and avoid claim denials and large patient bills.”
-Ashley (Insurance Verification Department)
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