Participating Insurance Companies

Aetna

• Aetna PPO
• Aetna EPO
• Aetna HMO
• Aetna Managed Care
• Aetna – All Texas narrow network plans
• Aetna Premier Care Network
• Aetna Premier Care Plus (“ACPN” – narrow networks)
• Texas Health Aetna – PCPs

Ambetter

• Superior Ambetter Commercial Marketplace EPO
• We do NOT take Ambetter focused value plans

Baylor Scott and White

 

BCBS

• BCBS PPO (BlueChoice Network)
• BCBS EPO (BlueChoice Network)
• BCBS PPO/POS plans offered through Blue Card (out of state plans)
• BCBS HMO** (Blue Essentials)

Cigna

• Cigna PPO
• Cigna POS
• Cigna EPO
• Cigna OAP
• Cigna HMO**
• Cigna Network
• Cigna Great West Plan
• Cigna LocalPlus

Coalition America (Formerly NPPN)

Coastal Comp Workers Comp

FedMed – PPO

First Health

• First Health/Coventry Network – PPO
• First Health/Coventry Network – WC

Friday Health Plan

• Friday Health Plan – EPO/PPO (Dallas)
• Friday Health Plan – EPO/PPO (Rural)
• Friday Health Plan – EPO/PPO (Tarrant)

Healthcare Highways

• Healthcare Highways
• Healthcare Highways ACO
• Healthcare Highways Commercial

Galaxy

• Galaxy Healthcare PPO
• Galaxy Medical Savings Plan

Healthsmart

• HealthSmart ACCEL
• HealthSmart GEPO
• HealthSmart PPO
• HealthSmart/Interplan Health Group WC

Humana

• ChoiceCare (Humana) – Concentric (Humana Preferred)
• ChoiceCare (Humana) – Medicare Advantage HMO** (PCP)
• ChoiceCare (Humana) – Medicare Advantage PFFS
• ChoiceCare (Humana) – MedicareChoice PPO
• ChoiceCare (Humana) – PPO
• Humana Choice Care PPO
• Humana MA ACO

IMS PPO

Medicare

• Aetna Medicare Advantage PPO
• Aetna Medicare Advantage HMO
• Aetna Medicare Prime HMO* (Eligibility determined by Aetna only, dependent on hospital privileges)
• Superior Medicare Advantage HMO**
• BCBS Medicare Advantage PPO
• BCBS Medicare Advantage HMO**
• Care N Care Medicare Advantage
• CMCHP – Medicare Advantage
• First Health/Coventry Network – Medicare Advantage PPO
• Humana Medicare Gold Plus HMO**
• Humana Medicare Choice PPO
• Humana Medicare Gold Choice PFFS
• Mutual of Omaha Medicare Advantage
• Texas Bluebonnet – Medicare Advantage
• Wellcare Medicare HMO

Molina

• Molina – Marketplace (Dallas-PCP)
• Molina – Marketplace (Rural-PCP)
• Molina – Marketplace (Tarrant-PCP)

MultiPlan

• MultiPlan Auto Medical
• MultiPlan Complimentary Network
• MultiPlan Workers Compensation

PlanVista – PPO

Texas Bluebonnet

• Texas Bluebonnet – EPO/HMO/PPO

UA TexanPlus Medicare Advantage

UAM TexanPlus ACO

United Healthcare

• United Healthcare – HMO**/PPO
• United Healthcare – Secure Horizons/Evercare (Dallas)
• United Healthcare – Secure Horizons/Evercare (Rural)
• United Healthcare – Secure Horizons/Evercare (Tarrant)
• United Healthcare PPO
• United Healthcare POS
• United Healthcare EPO
• United Healthcare HMO**

USA MCO – GPG

USA MCO Workers Compensation – GPG

Value Based Care (VBC) Program – Aetna Medical Neighborhood
Wellcare

• WellCare HMO ACO

** Requires Referral Authorization Letter/Referral From PCP

FAQ on Insurance

Why do I have a large insurance balance on my EOB?

Typically you will have a large insurance balance if insurance has denied a claim and we need to resubmit the claims with provider notes to prove medical necessity. When claims are being resubmitted, insurance can be slow with processing. Although rare, from time to time we may need to adjust coding if errors have been made or add diagnoses to help meet medical necessity. This can take as little as a few weeks to a few months to complete processing depending on insurance response times. Please check with your insurance regarding claim processing times. You can also see when claims are processed on your insurance portal. If neither of these options work please check back with our billing department within 4-6 weeks after claim submission.

Why do I have a large patient balance?

This is highly unusual as most patients have excellent coverage of coaching visits, but this can vary similar to an insurance balance. We try our best to get an estimate on the cost of services from your insurance prior to your appointment, however, we are limited by the representative we speak with and the information provided on the insurance portals. We are only given an estimate of costs and coverage can vary once claims are submitted. We may be told that a copay applies, when in fact the coverage goes towards your deductible or coinsurance. We always recommend  that you touch base with your insurance to verify coverage prior to any service being rendered.  Final determination of costs is always made by your insurance carrier once a claim is submitted, not by the medical practice.

What is the difference between coverage for seeing an MD/PA vs the other Vitality coaches?

Coverage for an MD or Physician Assistant visit is considered a medical office visit and the cost is similar to any other specialist visit.  This could be a copayment amount or a coinsurance amount that applies towards your deductible. Every plan is different and coverage can vary depending on which plan you have chosen. A new patient appointment can be a higher out of pocket cost than a follow up visit based on your covered benefits.

Coaching visits (such as visits with dietitians, personal trainers, mindset coaches and counselors) are all considered counseling visits.  

Whether these are covered are dependent on your insurance plan, but usually most patients do have at least ONE visit covered. Clinician visits are billed two ways with differences described below:

99402/99403/99404 (Dietary Counseling)

96158 (Behavioral Intervention) 

What is CPT code 99402/99403/99404?

• Usually covered at 100% (no copay; does not go towards or depend on your deductible) 
• Usually free for you (because insurance pays for the visit)
• The number of visits covered varies by insurance plan, some cover “unlimited” visits and some cover a defined number of visits (ie 10 visits).

What is CPT Code 96158?

• Sometimes comes out of the patient’s deductible if patient has not met the maximum out of pocket yet
• Often has a copay such as $25-30

We will always try to bill your coaching visits with the 99402/99403/99404 CPT code first when appropriate, but based on what is discussed at the appointment and number of visits covered by your insurance plan for that code, that is not always possible.  

What is the difference between a copay vs deductible vs coinsurance?

A copay is a set rate that you pay for doctors visits and other types of care. This amount is set based on your specific plan/coverage. For example, this could be $25 per appointment.

A coinsurance is a percentage of costs you are responsible for after you’ve met your deductible. If a coinsurance applies for your visit, instead of a copay, you will be responsible for 100% of your medical cost until your deductible has been met. Once your deductible is met you will pay a percentage of costs set by your insurance until your out of pocket is met. 

Example: 80/20. Your plan will pay 80% and your out of pocket will be 20%.

A deductible is the amount you pay for out-of-pocket costs for your covered health care before your plan begins to pay. You should always check with your insurance carrier to verify if a deductible applies towards your healthcare benefits. This could result in you having to pay out of pocket for your visit.

I was told my visits are covered at 100% but now I have to pay X amount.  Why?

When we call insurance companies to get information on cost and coverage, it is an estimation, not fact or a final answer. We are limited to who we speak with and the information provided on the insurance portals.  We may be told that a copay applies, when in fact the coverage goes towards your deductible or coinsurance. Final determination of costs is always made by your insurance carrier once a claim is submitted, not by the medical practice.  We always recommend  that you touch base with your insurance to verify coverage prior to any service being rendered.  

How much is a new patient visit?

The cost of a new patient visit varies depending on your insurance plan.   You may have to pay a copay, coinsurance or the full deductible amount (if you have not met your deductible yet).  If you are required to pay the full deductible amount your new patient visit could range from $175-$300 depending on the contracted rate we have with your insurance and follow up medical visits are between $100-200.