Making Sense of Your Insurance: A Guide for MFM Health Patients

We work with a variety of insurance providers, but coverage depends on your specific plan. Contact your insurance company to confirm whether we are considered in-network. Use the member services number on your insurance card for accurate information.

Visit our Insurance Info page and click on "Find Your In-Network Provider" under the quick links to find a list of the major carriers. Please note this is note an exhaustive list.

To verify coverage for a specific provider, you can look up their National Provider Identifier (NPI) number on their bio on our website and provide it to your insurance company. This ensures accurate information when checking coverage. Be sure to ask:

• Is Dr. [Provider Name] in-network under my plan?

• What are my copayments, coinsurance, or deductible amounts for this provider?

• Are there services provided by this doctor that are not covered?

If you're verifying specific procedures or services, it may also be helpful to ask our office for the CPT (Current Procedural Terminology) and diagnosis codes for the services you’ll be receiving. Providing these codes to your insurance company can help ensure accurate benefit verification. Contact our billing department for help obtaining CPT and diagnosis codes.

Some insurance plans require a referral to see a specialist. Insurance plans that always require referrals for specialty care include the following plan types: All HMO or POS plans for any insurance payor, Fallon, Masshealth, Mass General Brigham, and Wellsense (formerly BMC).

To confirm if your plan requires an insurance referral, please call the member services phone number on the back of your insurance card. Some helpful questions to ask include:

• Does my plan require a referral from my PCP?

• How do I obtain one, and what services does it cover?

• Will my visit be covered if I don’t have a referral?

Pre-authorization is often required for certain procedures, treatments, or specialist visits. Contact your insurance and ask:

• Does my plan require pre-authorization for the services I’ll be receiving at MFM Health?

• How do I obtain pre-authorization, and who handles the paperwork?

To streamline the process, you can request CPT (Current Procedural Terminology) and diagnosis codes for the planned services from our office. Sharing these codes with your insurance company can help clarify their requirements. Please contact our billing department to obtain CPT and diagnosis codes.

If your MFM Health provider orders advanced imaging such as a CT Scan or MRI, our team will obtain a prior authorization for these services on your behalf and will work with you to schedule an appointment.

Some medications require prior authorization before the pharmacy will fill your prescription. Our team will obtain medication prior authorizations for prescriptions they order on your behalf. In the event the team is unable to obtain a prior authorization, our clinical team will work with you to identify an alternative medication.

Coverage for lab work and diagnostic tests varies by insurance carrier. To confirm, contact your insurance and ask:

• Are labs or diagnostic tests ordered by MFM Health covered under my plan?

• Is there a separate copayment or deductible for these services?

• Will I need pre-authorization for any tests?

• Will I need pre-certification or prior authorization for any tests?

It’s also helpful to ask our office for the CPT (Current Procedural Terminology) and diagnosis codes associated with the specific tests being ordered. Providing these codes to your insurance company ensures they can verify coverage accurately. Please contact our billing department to obtain CPT and diagnosis codes.

If your insurance information has changed, please notify us as soon as possible to ensure accurate billing. You can update your insurance details by contacting our billing office.

You. may also want to contact your new insurance company to confirm:

• Is MFM in-network under my new plan?

• Do I need to update or obtain new referrals or prior authorizations?

• What additional steps should I take to ensure my new insurance is accepted at MFM Health?

If a service or provider is out-of-network, you may have higher out-of-pocket costs. Ask your insurance company the following questions:

• What are my out-of-network cost share responsibilities?

• Will any portion of the cost be covered?

• Do I have other options for coverage of these services?

It’s also helpful to ask our office for the CPT (Current Procedural Terminology) and diagnosis codes associated with the specific tests being ordered. Providing these codes to your insurance company ensures they can verify coverage accurately. Please contact our billing department to obtain CPT and diagnosis codes.

When contacting your insurance company, ask about the specific costs associated with in-network versus out-of-network services. Key questions include:

• What is my copayment for a primary care visit? A specialist visit?

• What is my deductible, and how much have I met so far this year?

• How much will I be responsible for if MFM Health is out-of-network for my plan?

• Are there any additional fees or charges I should be aware of for services like labs or diagnostic tests?

Having the CPT (Current Procedural Terminology) and diagnosis codes for planned services can be helpful when discussing costs with your insurance provider to ensure clarity on potential charges. Please contact our billing department to obtain CPT and diagnosis codes.

Once your insurance has been billed, you will receive an Explanation of Benefits (EOB) from your insurance company. This document explains what services were billed, how much your insurance covered, and any remaining balance that you may owe. If you have any questions or feel there was an error, please contact our billing office.

Yes, we offer flexible payment plans to help patients manage their medical bills. Please contact our billing department to discuss available options.

For any billing inquiries, you can reach our billing department. Our team is happy to assist with any questions regarding charges, insurance, or payment options.

If your insurance information has changed, please notify us as soon as possible to ensure accurate billing. You can update your insurance details by contacting our billing office.

If your insurance denies a claim, you will receive a notification explaining the reason for the denial. Our billing department can assist you in understanding the reason for the denial and provide guidance on how to appeal the decision if necessary. You may also be responsible for the balance if your insurance company does not cover the service.

Yes, if you have secondary insurance, we will submit claims to both your primary and secondary insurance providers. Please ensure we have up-to-date information for all of your insurance plans.

Your deductible is the amount you need to pay out-of-pocket before your insurance starts covering certain services. However, copays are separate fees required for specific services, such as office visits or specialist consultations, and are often required regardless of whether you’ve met your deductible.

Please contact your insurance company for more information about your out-of-pocket payment responsibilities.

You may receive separate bills for different services provided during your visit. For example, a lab test or imaging service may be billed separately from your MFM Health office visit. If you have any questions about specific charges for services you received at an MFM Health location, feel free to contact our billing office for clarification.

If your MFM Health provider orders testing or imaging at an external, non-MFM Health facility, those services will be billed separately by the outside provider. For any questions or concerns regarding bills for these services, please contact the billing department of the external facility directly.

Yes, we can provide a cost estimate for many services. Please contact our billing office before your visit to request an estimate based on your insurance plan and the services you may need.

If you believe there is an error on your bill, please contact our billing department as soon as possible. We will review the charges and work with you and your insurance company to resolve any discrepancies.

Yes, missed appointments without proper notice may result in a fee. We ask that patients cancel or reschedule at least 4 hours in advance to avoid being charged for a missed visit. Please see our No Show/Late Arrival policy for more information.

Insurance companies have coverage limitations based on your specific plan. If a service is not fully covered, or if it’s considered out-of-network, you may be responsible for the remaining balance. Our billing team is happy to help clarify what your insurance covers and for what portion you are responsible.

You may have received a bill for your annual exam because certain services performed during the visit may not be covered under your preventive care benefits. Annual exams are typically covered in full as preventive care; however, if additional issues were addressed, such as new concerns, chronic condition management, or diagnostic tests, these may fall outside of preventive coverage and be billed separately.

For a detailed explanation of what may impact your bill, visit our blog post here: Why Did I Get a Bill for My Annual Exam?