Frequently Asked Insurance Questions
These are some of the questions people most frequently ask us about insurance:
Do You Submit Claims to Insurance?
We do not bill insurance directly on behalf of patients. Instead, we provide a detailed superbill so that patients can submit claims directly to their insurance for reimbursement.
What is a Superbill?
A Superbill is basically a fancy receipt that we can print or email to you after every treatment that includes all the essential information your insurance company needs to process your medical claim. This includes the date of service for your treatment, the procedure (CPT) codes for that treatment, your diagnosis (ICD-10) code (what we’re treating you for), and the cost of each service.
How Can I Get a Superbill?
You can request one directly from us and we can either print it after your appointment and give it to you before you leave, or we can email it to you. We can make a note in your patient profile to do this after every visit if you plan to submit claims to your insurance for reimbursements.
Are You In-Network or Out-of-Network?
We are considered out-of-network for all insurance companies.
Do You Accept Medicare?
We do not accept Medicare policies. We can provide you with detailed Superbills to submit claims directly to Medicare for reimbursement.
I Have Access to a Union Fund – How Can I Use This For My Acupuncture Treatment?
If you have access to union funds that you would like to use for treatment, you can provide them with a Superbill, and they can reimburse you directly depending on what they consider an eligible service. Your union representative will be best equipped to answer any questions about eligible services and their preferred process for submitting claims.
Can I Use My FSA/HSA Card For Treatments?
Yes, we accept HSA and Flex Spending as payment for your visits! Be sure to review your specific account guidelines to understand what expenses are eligible for reimbursement.
What is a CPT code?
A CPT (Current Procedural Terminology) code describes a specific medical service or procedure performed during a healthcare appointment and lets your insurance company know what services were performed during your treatment. The three most common codes we use for services are:
- 97810 - Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes.
- 97811 - Acupuncture, one or more needles, without electrical stimulation, each additional 15 minutes.
What Does the ‘CP’ After the CPT Code on my Superbill Mean?
The ‘CP’ label following your CPT code on your Superbill stands for ‘Cash Patient’. We use this to notate that you are considered a cash patient, meaning you paid cash rates for treatment with us. The notation does not affect the CPT code, and your insurance will be able to process your claim.
What is a Diagnosis Code?
Your diagnosis code, or your ICD-10 code, is what tells your insurance company what medical condition we are treating you for. Your insurance company uses this code to understand the purpose of your visit and determine your eligibility for coverage. Every policy is different, and certain policies might have specific guidelines about what kind of conditions they will provide reimbursements for when getting acupuncture treatment. We recommend studying your policy and reaching out to your insurance company to understand what kind of guidelines or restrictions they have for eligible conditions when it comes to acupuncture treatment.
What is a Claim?
A claim is what you submit to your insurance company to let them know that you received a service that is eligible for coverage under your policy. It’s a formal request by you that essentially outlines all the important information contained in your Superbill – when you were treated with us, what the treatment was for, etc. Your insurance company will have either a paper form you can mail directly to them or will have an electronic form that you can access online. This information would have been provided to you when you enrolled in your policy.
What is an Explanation of Benefits (EOB)?
An Explanation of Benefits is a statement that your insurance company sends to you in response to you submitting a claim. It includes information about how the claim was processed, the amount that was applied to your deductible if you are still meeting a deductible, or the amount of the service that they are providing coverage for.
What is a Deductible?
Your deductible is what you pay out-of-pocket for healthcare services before your insurance will start contributing to your healthcare costs. Let’s say your policy tells you that you have a $1,500 deductible for out-of-network healthcare services. You would need to pay $1,500 in out-of-network expenses before they begin to provide any reimbursements or coverage.
What is a Co-Pay?
A co-pay is a fixed amount that you would pay for a covered healthcare service, which is usually due at the time of service. The number is set by your insurance plan. Since we do not provide direct insurance billing, you would pay the cost of each treatment up-front.
What is Co-Insurance?
Co-insurance is the percentage of costs shared between you and your insurance company AFTER you've met your deductible. For example, if your co-insurance is 20%, you would pay 20% of covered expenses, and your insurance would cover the remaining 80%.
What is an Out-of-Pocket Maximum?
The out-of-pocket maximum is the maximum amount the insured individual is required to pay in a policy period. Once this limit is reached, the insurance company covers 100% of covered expenses. It is a way to protect individuals from high healthcare costs.
What Kind of Questions Might my Health Insurance Company Ask Me?
If you call your insurance company to ask about your coverage, they might ask you questions like:
- What is the name of the facility that you are receiving treatment from?
- What kind of facility are you receiving treatment from?
- What are you getting treated for?
- What is the date of service you received treatment?
- What is the type of treatment you received at your appointment?
We recommend having your Superbill available when calling your insurance company.
How do I Know if my Insurance Company Covers Acupuncture?
You have a few ways to check if your insurance company has out-of-network insurance coverage. The most efficient way is to use the number listed on the back of your insurance card. A member services representative should be able to answer any questions you have about your coverage, deductibles, claim status, etc. Most insurance companies also have a member portal that you can log into and view details about your insurance policy, coverage, deductibles, and claim status.
What Should I Consider When Shopping for an Insurance Policy?
When shopping for insurance, it's important to get an idea of what their acupuncture benefits are. You can ask them questions like:
- What coverage do you offer for out-of-network acupuncture benefits?
- Do you offer out of network acupuncture benefits if the acupuncturist is independent, and not contracted with an MD or DO?
- Can you tell me how much the allowable is for out-of-network acupuncture services, and how much of that allowable is covered?
- Do you have any diagnosis codes that you don't cover?
- Is there an annual max for acupuncture visits this policy stipulates?
- Do you require prior authorization for treatment?
- Do you require a medical review after a certain number of visits?
- Can you tell me how much I could expect to be reimbursed if I submitted a claim with the CPT codes 97810 and 97811?
This information can give you a better idea of what you can expect from a prospective insurance policy when it comes to acupuncture coverage so that you can make informed decisions about your policy selection.
Are you Considered an Outpatient, In-Patient, or Professional Facility?
If your insurance company asks you to clarify the type of facility we are, you can identify us as a Professional Facility. Often, insurance companies will give you a choice of three types of facilities and ask you to clarify which one you received treatment at. These are the three types of facilities they typically ask, and an explanation of each:
- Professional Facility: A professional facility focuses on outpatient care where patients visit an office for consultations, exams, or treatments without staying overnight.
- Inpatient Facility: An inpatient facility provides 24-hour care for patients requiring overnight stays, like for a surgery or complex treatment.
- Outpatient Facility: An outpatient facility is like a professional facility in the sense that they also provide outpatient care where patients visit an office for consultations, exams, or treatments without staying overnight. However, outpatient facilities are typically associated with larger hospitals and medical centers.
Are you Contracted with an MD or a DO?
Our clinic is not contracted with either Medical Doctors (MDs) or Doctors of Osteopathic Medicine (DOs). We specialize in acupuncture and traditional Chinese medicine, which are distinct modalities from conventional medical practices. Some insurance plans will only offer coverage if the acupuncture clinic is contracted with an MD or DO, and so it’s important to understand if your policy requires this.
How do I Submit Claims to my Insurance?
For specific instructions on submitting claims to your insurance company, please visit your insurance company website or contact their customer service. They typically provide online portals or specific forms for claims submission. Some common insurance carriers that we have worked with in the past include UHC, Anthem, BCBS, Humana, UMR, Cigna, and Dean Health Plan.
What is an Employee-Sponsored Health Plan?
An Employee Sponsored Health Plan is a health insurance plan provided by an employer to its employees. It often includes contributions from both the employer and the employee and offers group rates, making it a cost-effective option for coverage.
We understand that insurance billing can be challenging. If you have any questions that we have not been able to answer here, you can reach out to us, and our Clinic Director or Office Manager will be able to assist you.