Providers/CA - Insurance

What will happen if claims are not sent to AHC or I-AHC when they should be?

There are several results from claims not being sent to AHC or I-AHC. These include:

  • Lower reimbursements
  • Higher out of pocket expense for patients
  • Frustrated providers and patients when they try to correct the claims
  • Delayed reimbursements
  • Increased cost
  • Lower fee schedules will be proposed by network affiliates to I-AHC
  • Opportunity for less provider friendly companies to secure contracts

How and where should claims be filed?

In most cases, claims should be sent directly to AHC. In a few cases, the claims would be sent to the address on the insurance card. This is determined during the contracting process and specified on the term summary sheets. AHC distributes a list of network affiliates with claims filing instructions several times a year. If you need an updated list or term summary sheets, please contact our office or visit our website at ActivHealthCare.com.

Can I balance bill a patient for the amount not paid by the insurance carrier?

Sometimes, depending on what was not paid and the reason.

For example, patients are responsible to pay you for co-pays, deductibles and coinsurance portions that are not paid by the insurance carrier. The patient may also be billed for items that are specifically not covered by the insurance plan, i.e. vitamins, cervical pillows, massages, etc. However, you must let the patient know in advance and in writing that certain items may not be covered and will be the patient's financial responsibility.

Will the insurance carrier or third party administrator know who AHC is?

No, they probably will not. Remember, we contract with the PPO, HMO or MCO network. We do not contract directly with the claims payor. The PPO, HMO or MCO has the contract with the claims payor. For example, the claims payor normally does not know that NovaNet uses AHC chiropractors. There are several hundred companies paying NovaNet claims throughout the country. By contracting with AHC, your name is placed in the directories of all the NovaNet PPO plan participants.

How do you verify a patient's insurance benefits?

You would call the number on the insurance card to verify coverage and obtain a description of benefits. In some cases the insurance carrier will ask for your tax identification number to determine if you are a participating provider. If that happens, you should provide them with AHC's tax identification number.

Which claims should you submit through AHC?

You should only submit the claims for patients affiliated with the AHC contracted networks. Most of our contracts require you to submit the claims through AHC. A few of the contracts provide for direct billing from you to the payor. Those contracts are identified on our list of current contracted networks.

Will the insurance carrier or third party recognize me as a Preferred Provider if I do not use AHC?

No, not unless you have a direct contract with the PPO, HMO or MCO. You are listed as a PPO, HMO or MCO participating provider through your affiliation with AHC. As such, you are recognized by the AHC tax identification number and billing address.

What if the insurance carrier or claims payor does not recognize me as a participating provider?

If the patient's coverage uses an affiliated network, but the claims payor or insurance carrier does not recognize you as a participating provider contact the AHC customer service department.

How will you identify which patients are affiliated with AHC networks?

The employer or insurance carrier will identify the PPO which the patients should use by placing either the name or logo of the MCO or PPO on the insurance identification card. If it is not on the identification card, you should ask for the name of the PPO network when you verify insurance coverage.