Billing and Insurance

Patients are encouraged to seek care from a “Participating” or “In-Network” physician or “Provider” in order to receive the highest level of reimbursement under their health plan. As a participating network provider, the provider has contracted with the managed care health plan or “Network” to provide services at a negotiated fee which is typically less than the provider’s normal billable rated charge.

The negotiated fee or “Contract/Network Discount” is provided to the provider and patient, in a statement referred to as the “Explanation of Benefits”, upon processing of the insurance claim.

It is important that patients review these statements carefully to insure claims are paid according to the patient’s benefits and plan coverage. The amount noted in the patient responsibility does not include payments already made to the provider for the services. This would mean if the amount shown in the patient responsability was already paid to the provider, additional payment would not be due.

Our Pediatric Clinic files insurance claims for all health plans in which we participate.

If Pediatric Clinic of Mesquite, Garland or Sunnyvale does not participate with your health plan, payment is due at the time services are rendered for treatment in the office and the patient must file insurance for reimbursement. As a courtesy, Pedcare, PA will file insurance for hospital services, regardless of plan participation. Patient amounts due for hospital services after insurance, will be billed to the patient once insurance has been processed.

An itemized receipt is provided by our Pediatric Clinic at the time of check out. Additional copies may be obtained by contacting the appropriate account representative, in our Billing Office.

This receipt is required when submitting a claim to the patient’s insurance company for reimbursement. Most insurance companies require a claim form be completed and submitted to the insurance company along with the itemized receipt.

Claim forms can usually be obtained from the employer or insurance company by requesting via the telephone or downloading from the insurance company’s website. The address for submitting claims can typically be found on the insurance card or in the plan benefit booklet provided by the health plan.

Please contact our office if you do not see your insurance plan listed below. Or check with your insurance company to determine if we are an in-network provider.

Private Insurance 

• Aetna Health Plans POS and PPO
• Blue Cross POS and PPO
• Blue Choice POS and PPO
• Cigna Health Plan HMO, POS, PPO, OAP, and Local Plus
• First Health PPO
• Great West PPO
• HealthSmart ACCEL
• HealthSmart GEPO
• HealthSmart PPO
• Humana-Choice Care PPO
• Integrated Medical Systems PPO
• MultiPlan PPO
• MultiPlan Viant/Beech/ppoNext PPO
• PHCS PPO * Multiplan
• Texas Bluebonnet Health Plan PPO, EPO, HMO
• United Healthcare PPO, HMO, POS, and Compass EPO
• UMR
• Molina Marketplace
• Boon Chapman
• Caprock

Medicaid Plans

• Amerigoup
• Amerigroup CHIP
• Parkland
• Parkland KIDSfirst
• Molina
• Molina CHIP
• TMHP 
• Superior
• United Healthcare Medicaid
• Children’s Medical Center Health Plan

If your insurance requires a PCP please make sure one of our providers is the selected PCP at the time of service.

We are pleased to service our families by providing quality medical services and assisting in the billing process. However, it is important that our families understand that ultimately the financial responsibility of these services rests between the patient and the health plan. We hope this summary will be helpful in understanding your insurance and obligations.

The patient, parent or guardian accompanying the patient is responsible for providing our office with a valid and current insurance card. We must be notified of any changes, prior to rendering services. Patients unable to provide valid insurance information may be required to pay in full at time of service or reschedule their appointment.

The patient, parent or guardian accompanying the patient must pay any co-payment and applicable deductible amounts, as directed by insurance, at the time of service unless prior arrangements have been made with our office.

The bill will be sent to the health plan on record for direct payment to our office.

If insurance has not paid our claim within 60 days, we may expect payment from the patient.

If by mistake, the health plan remits payment to the patient, payment should be forwarded to our office along with all the paperwork sent to you at the time.

The patient, parent or guardian will remain responsible for any services that are not covered or noted as patient responsibility by the health plan.

Some of the reasons health plans may refuse or deny payment of a claim are:

• The provider of service is not listed as the primary care physician “PCP” for the patient, and/or no referral was obtained or the provider is out of network.
• Services provided were for a pre-existing illness that is not covered by the patient’s health plan.
• The patient’s deductible or co-insurance amount has not been met.
• The type of medical services received is not covered by your plan or subject to a maximum benefit allowance (generally per calendar year).
• The health plan was not in effect at the time the service was rendered.
• The patient has other insurance noted as the primary carrier which must be filed first.
• The insurance company requires the patient to contact them regarding whether or not the patient is covered by another health plan (generally required to update at least annually).
• Services indicate the patient was seen for an injury or accident. The patient must provide information regarding the accident or injury to the health plan as requested, before the claim will be paid.
• The patient or dependent receiving the services is not showing as a covered dependent under the health plan.

Please note that payment collected at the time of service may not reflect the full patient responsibility after insurance. Our office is not responsible for any limitations in coverage that may be included in your plan. Should your health plan deny claims for any of the above reasons, you will then become responsible for the bill. It is the responsibility of the patient to pay denied amounts in full. We advise our families to understand their insurance benefits and review explanation of benefits and patient billing statements carefully. If you feel there has been an error, always contact the appropriate party with questions within a timely manner. Patient amounts owed are considered past due 30 days after the date of the initial billing statement. Anytime the patient is aware there will be a delay in payment, whether by the patient or insurance, it is important to notify our billing office of the situation. Pedcare Medical Group, understands that circumstances can sometimes arise. However, to allow additional time to pay, work through insurance problems or to establish other payment arrangements, we must be informed.

We understand when a change in dependent status occurs it is likely to be a very busy time in our families’ lives. However, it can be very costly to overlook the requirements of your health plan with relation to dependent changes. It is extremely important to understand this process and time restrictions involved.

Upon the birth of a newborn dependent, adoption or other change to a dependent status, you must contact the employer and/or health plan to add new dependents within the time limits defined by the health plan. Most insurance companies require notification of the change within 30 days from the date of birth, adoption or event date. If you already had dependent coverage prior to the birth of a newborn, adoption, etc., please be advised the insurance company will not automatically add the new dependent to the health plan. Failure to add the new dependent may result in a lapse of insurance coverage for the new dependent, meaning all services provided during the lapse time are the responsibility of the patient. Contact the employer or health plan with further questions regarding this process.

Some health plans require insurance referrals or pre-authorizations in order to receive treatment from a specialist or for special services or medications. It is the responsibility of the patient to know their benefits and request the required referral or pre-authorization prior to receiving the services for which the referral or authorization is needed.

Continued failure to respond to billing statements or make payments may result in the suspension of certain non-urgent services and ultimately in dismissal from our practice. Please be advised outstanding debts will be forwarded to a collection service where unpaid balances will be reported to the appropriate credit agencies. Should you feel you have made an overpayment to our office or are awaiting a refund based on insurance reimbursement, please contact the appropriate account representative in our Billing Office with questions. If you are entitled to a refund, our office will issue a refund check to the responsible party listed on the account, upon request. Due to the frequency of visits in pediatrics, if we do not receive a specific request for a refund, overpayments are applied as a credit to the patient’s account and applied towards future visits in our office.

Should you have any questions about this summary or any billing issues, we encourage you to discuss it with our Billing Office. We appreciate your dedication to our physicians and are happy to have your family as part of our practice. We look forward to providing many years of service to your family.

Call us for the following administrative services:

• Patient Accounts
• Insurance Questions

Should you have any questions regarding medical records or physician referrals, please call the front desk, and as to be transferred to referrals.

In addition to contacting us directly, our online feedback form is available for your use!

Our clinics strive to provide quality, compassionate care to all of our patients If you are dissatisfied with your experience, please contact us immediately so that we may remedy the situation. We hope to continue improving, and strive for excellence, and we ask for your help in achieving this goal.

Release of Medical Records Policy

In keeping with this practice’s duty to protect patient confidentiality, we will not release confidential medical information without strict adherence to state and federal laws, rules, and regulations.

Original medical records are the property of the treating physician and as such will not be released from this facility unless in accordance with a court order, subpoena, or statute. Original medical records are never allowed to leave this facility without prior authorization and approval by the treating physician(s).

This facility recognizes the right of patients to obtain copies of their medical records or have them forwarded to another designee such as a relative, physician, or attorney.

A fee is charged for copying, mailing, or otherwise complying with any approved request for the release of medical records in accordance with limits set by the Texas State Board of Medical Examiners.

Oral requests for the release of medical records will not be honored. Any patient requesting release of his or her medical records must complete the attached Medical Records Release Form. Alternative release forms will be accepted only at the discretion of the office manager and/or Medical Records staff.

A parent or legal guardian will be required to sign the Medical Release Form when the patient is a minor. No other persons will be permitted to sign a record release in lieu of patients without a court order or similar legal directive.

The patient, or other person authorized to consent, has the right to withdraw consent to the release of any information. Such withdrawal must be in writing. No information should be released after consent has been withdrawn.

A copy of the written Medical Records Release Form must be retained and placed in the patient’s permanent medical record.

Medical Records Release Form here