Optimal Health Medicine Center
Integrative, Holistic, Functional Medicine
In order to have the freedom to provide health care that is not driven by insurance company reimbursement schedules, we have made the choice to have an “out-of-network” relationship with them. We are a non-participating provider in private insurance company plans, HMO’s, and PPO’s. We have “opted out” of Medicare and Medicaid programs. If you have one of these plans, we will provide you with the documentation you need to file your claim in the form of an itemized invoice that lists the appropriate diagnosis codes your insurer requires.
In the case of Medicare and Medicaid, the government regulations require that both the physician and the patient agree “not” to seek reimbursement if you choose to private contract with us. A sample can be provided upon request.
We do not know the details of the private insurance plan you are covered by and, therefore, cannot predict what will be reimbursed. Each plan has been negotiated by your employer or other organization and has different deductibles and coinsurance percentages. Please contact your insurance company or Human Resources representative to determine what your coverage for “out of network” medical care will entail.
Methods for filing vary by company, but generally, you will need to mail or fax the super bill provided at check-out to your insurer along with their claim form. You can obtain these forms from your employer or go to the insurance company web-site. You fill out the top portion of the form and where it says to send payment, check the box for reimbursement to you. The bottom portion is supposed to be filled in by the physician. You can write in “See Attachment” and send the itemized invoice discussed previously.
Requests for additional information by your insurance company will be handled through the patient only. We do not have the resources to spend time on the phone with customer service reps. from insurance companies trying to resolve individual claims. All reasonable requests will be taken care of via E-mail or fax. If you are still having difficulty getting reimbursed, contact your employer and ask them to intervene on your behalf. They often have an inside edge when dealing with an insurance company.
Finally, you are free to choose the lab your insurance company authorizes for typical blood work and other convential testing. However, some services or labs may not be covered as determined by your insurance company such as supplements, custom compounded prescriptions and specialized testing. These may be covered under a Flex spending account or other HSA (Health savings account). We cannot predict what your plan will reimburse. We will do our best to provide you with the proper documentation. Securing payment can be difficult, whether the services rendered are conventional or alternative. Your best bet is to keep close track of what and when you submit and challenge or appeal any decision they make which is not explained to your satisfaction. We will help you as best we can, but, in general, are not involved in claims processing beyond providing documentation for your office visit.
When you speak with your insurance company, ask about the "Gap Exception". You may be able to receive in-network benefits for an out of network doctor.