Insurance

Insurance

We are contracted providers (“in network”) with many PPO health plans.
For a complete list, click here.

We can not accept HMO insurance plans.

IMPORTANT!  We urge you to exercise caution when determining the provider network for your insurance, especially for non-employer sponsored plans.  With the implementation of the Affordable Care Act and the public health insurance exchanges, there has been much confusion about the different products offered by each insurer.  In an effort to offer lower cost health care policies, insurers have recently been creating “narrow provider network” plans.  Medical practices that agree to be part of these “narrow network” plans agree to receive lower payment for their services.  In effect, the insurers are passing the burden of the cost reduction to the medical practices in exchange for a greater number of patients in network. This would naturally appeal to big health care practices or systems that rely on seeing a large number of patients for their financial well-being.  Our small practice with limited patient volume does not allow us to accept discounted payments from insurance companies.

Blue Shield’s provider network has been especially confusing, as there are multiple new plans that utilize different provider networks.  Cigna also has new discount plans for which we are NOT in network, including their “Local Plus” plan.  In 2016, HealthNet has informed us that they are in the process of putting together similar “narrow network” plans that will be offered to individuals and small businesses as “low cost options”.  We will NOT be part of these “narrow” provider networks.  Please contact your insurance directly to be certain that your Coast Pediatrics Del Mar or Carmel Valley pediatrician is in your provider network.  Unfortunately, we are unable to answer these provider network questions and will direct you back to your insurance carrier.

Insurance Guidelines

Co-pays are due at the time of visit.

As contracted providers with insurance plans, we have agreed to accept certain payment amounts for most services that we provide, such as well checks, sick visits, vaccines, vision and hearing tests, etc.  Each insurance policy is unique, though, even within the same health plan.  Some carriers will not pay for certain services or will limit the number of well checks per year.  We cannot know specifically what will be covered by your plan nor can we verify this at the time of the appointment.  We encourage you to discuss your benefits with your carrier and to verify coverage for our most commonly used charge codes and schedule of well child visits prior to your visit.  Please rest assured that our practice is guided by what is medically necessary for your child, as well as by guidelines from the American Academy of Pediatrics.

Newborns must be added to your insurance plan within the first 30 days after birth for hospital charges to be paid by your insurance.

You are ultimately responsible for all charges incurred regardless of insurance payment.

Out-of-Network Insurance

If we are not contracted with your insurance, we can still provide medical care to your family as out-of-network providers. This means that we don’t have negotiated rates for our services with your carrier. We encourage you to contact your insurance carrier to determine your plan’s out-of-network benefits, to see what they will cover. You may also contact us for a list of our charges for the most common billing codes. We are happy to bill your insurance, but you are ultimately responsible for all charges incurred regardless of insurance payment. As with all out-of-network providers, there will be a difference between our charges and the amount that your insurance pays. Any balance remaining after insurance payment is due from you within 30 days. Keep in mind that this balance payment will be eligible for reimbursement from health savings or flexible spending accounts.

No Insurance

We also welcome families choosing not to use medical insurance. Payment is due at time of service.

We accept Mastercard, Visa, and personal check.

For any billing questions, please contact our biller at billing@coastpediatrics.com