Frequently Asked Questions - Providers/CA - Insurance

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.

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.

Be sure to ask about co-pays, deductible, coinsurance percentages, effective dates, chiropractic benefits and the other information listed on your insurance verification form. If the claim is for an accident, be sure to let the carrier know at the point of insurance verification. Your goal in the verification process is to obtain an accurate estimate of what will be allowed and paid by the carrier and what financial responsibility the patient will have to you.

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.

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.

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.

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.

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.

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.

The patient is not responsible for the portion of the claim that is denied due to PPO or network discounts. As a participating provider, you are agreeing to a fee schedule that is set by the PPO network and is approved by AHC. If your charge for a particular CPT code is over the fee schedule, the insurance carrier or claims administrator may deny a portion of your claim. You cannot bill the patient for the portion of the claim denied for this reason.

However, benefit plans often have limits on chiropractic care. Some plans limit the maximum benefit payable per visit, some limit the number of visits per benefit year and some limit both. You can bill the patient for claims that exceed the plan limits, up to the fee schedule amount for the services rendered. For example, if the services add up to $75 and the fee schedule for the services adds up to $58, the plan limit might be only $50 per visit. The patient is still responsible for the additional $8, if you choose to hold them responsible for it. Again, you should let the patient know in advance and in writing that they may be responsible for certain items and for services that exceed their plan limits. Our bulk pay remittance will distinguish between PPO or Network discounts and plan limits.

Some insurance plans require pre-certification of treatments, especially HMOs. You have an obligation to follow the rules of the patient's insurance plan. If you fail to obtain pre-certification and it is required, your claim might be denied. The patient and the plan will expect you to write off this type of denial. With that in mind, be sure to get clear answers to questions when verifying benefits.

And finally, some patients will change carriers and not notify you. They may provide you with the incorrect information. While you have an obligation to file claims in a timely manner, you cannot do so without the patient providing correct information. If the claim is denied because the patient did not provide accurate information, but you acted in good faith, you should balance bill the patient.

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