Insurance
Under your health plan, you are responsible for certain cost-sharing amounts, including copayments, coinsurance and deductibles. You may have additional costs or be responsible for the entire bill if Confluence Health is not within your insurance plan’s network. This is often referred to as “surprise billing” or “balance billing.” However, in many scenarios you are protected by law from receiving a balance bill for your care. For details on your rights as a patient with regards to balance billing, please click this notice.
If you have questions about your insurance, keep reading to see some answers to questions we receive from patients. You can also contact our Patient Financial Services Department at (509) 436-4020 or toll-free at (888) 499-4801.
Patient Financial Service staff are available from 8 a.m. to 5 p.m., Monday through Friday, at (509) 436-4020, or visit any of our in-person areas.
Many health insurance plans have pre-certification or prior authorization requirements for specific services and procedures. In some instances, referrals are required. Information about referrals is typically listed on the back of your healthcare insurance card. Please refer to your card, your benefits handbook, or contact your health insurance’s customer service department for more information on referral requirements.
Some important items to remember when obtaining an authorization or referral include:
- Allowed Amount
The amount the insurance company pays for a service (may be less than what we have billed). - Authorization / Pre-Authorization
Formal approval by insurance to assist patient and provider in securing payment for healthcare services. - Benefit Period
When services are covered under your plan. It also defines the time when benefit maximums, deductibles and coinsurance limits build up. It has a start and end date. It is often one calendar year for health insurance plans.
Example: You may have a plan with a benefit period of January 1 through December 31 that covers 10 physical therapy visits. The 11th or more session will not be covered. - Charge
Price for services rendered. - Coinsurance
A certain percent you must pay each benefit period after you have paid your deductible. This payment is for covered services only. You may still have to pay a copay.
Example: Your plan might cover 80 percent of your medical bill. You will have to pay the other 20 percent. The 20 percent is the coinsurance. - Contractual Allowance / Adjustment
The difference between what an insurance company approves according to its contract and what the healthcare provider charges for the service. - Copayment (Copay)
The amount you pay to a healthcare provider at the time you receive services. You may have to pay a copay for each covered visit to your doctor, depending on your plan. Not all plans have a copay. (i.e. $20 for every visit to the doctor, while your insurance pays the rest). - Cost
Patient’s out-of-pocket responsibility for services rendered. - Covered Person
Any person covered under the plan. - Covered Service
A healthcare provider’s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan. - CPT Code
Five-digit code(s) used to describe tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient. - Deductible
The amount you pay for your healthcare services before your health insurer pays. Deductibles are based on your benefit period (typically a year at a time).
Example: If your plan has a $2,000 annual deductible, you will be expected to pay the first $2,000 toward your healthcare services. After you reach $2,000, your health insurer will cover the rest of the costs. - Dependent Coverage
Coverage for your dependents who qualify. - Explanation of Benefits (EOB) or Explanation of Payment (EOP)
These are documents showing a detailed listing of how your insurance company processed your claim or bill. An EOB or EOP is mailed by your insurance company directly to you. - Established Patient
For billing purposes, an established patient is defined as someone who has been seen by the provider/department within the last three years. - HCPCS
Is a collection of standardized codes that represent medical procedures, supplies, products and services. - HMO – Health Maintenance Organization
An HMO requires the member to choose a provider network and a Primary Care Provider (PCP) within the chosen network. An approved referral from his/her PCP must be in place for a member to see a specialist. If a referral is not in place prior to receiving non-emergent care, the HMO may not cover incurred services. - Inpatient Services
Services received when admitted to a hospital and a room and board charge is made. - Insurance
Coverage that pays for medical and surgical expenses incurred by the insured and/or eligible dependents. - Medicare A
Medicare Part A provides payments for inpatient hospital services, excluding those of physicians and surgeons. - Medicare B
Part B provides payments to physicians and surgeons, as well as for medically necessary outpatient hospital services (such as ER, laboratory, X-rays and diagnostic tests) and certain durable medical equipment and supplies. - Medicare Advantage Plan
Medicare Advantage plans are private health plans that have contracted with Medicare. These plans are paid fixed subsidies by Medicare to provide Medicare beneficiaries benefits. Most of these plans are managed care plans, which are plans that control both the financial and health services portion of the insurance plan. - New Patient
For billing purposes, a new patient is defined as someone who has not been seen by the provider/department within the last three years. - Non-covered Charges
Charges for services and supplies that are not covered under the health plan. Examples of non-covered charges may include things like acupuncture, weight loss surgery or marriage counseling. Consult your plan for more information. - Observation
Is a special service or status that allows physicians to place a patient in an acute care setting, within the hospital, for a limited amount of time (generally 24 to 48 hours) to determine the need for inpatient admission. - Outpatient Services
Services that do not need an overnight stay in a hospital. These services are often provided in a doctor’s office, hospital or clinic. - OON – Out of Network
Health care rendered to a patient outside of the health insurance company’s network of preferred providers. In many cases, the health insurance company will not pay for these services. Emergency medical care is usually an exception to the OON rule. - Out-of-Pocket Maximum
The most money you will pay during your coverage period, includes deductibles, co-payments, co-insurance and balance-billed charges, but is in addition to your regular premiums. - POS – Point of Service Program
A POS has the same requirements as an HMO. However, members are given the additional option of self-referring outside of their PCP network. Members who choose to self-refer will incur a higher out of pocket cost. - PPO – Preferred Provider Organization
A PPO offers a network of providers. Members have the choice to access several providers but are given financial incentives (i.e., lower out-of-pocket costs) to use the preferred provider network. - Premium
Payments you make to your insurance provider to keep your coverage. The payments are due at certain times. - Price
Price of premiums, price of services. - Primary Care
General Internal Medicine, Family Practice and Pediatrics providers. - Prior Authorization
A request for payment authorization submitted in advance by a healthcare provider to the insurance plan for their approval to admit a patient, perform a procedure or provide a service. Pre-authorization / prior-authorization requirements are specific to each insurance plan. The insurance plan will determine medical necessity, appropriateness of services and level of care based upon their own guidelines. - Referral
An insurance pre-approval required from the patient’s PCP BEFORE seeing a specialist. - Self-refer
An insurance member’s ability to receive specialty care services without written referral from member’s primary care provider and approval from their insurance. These services, however, may be denied or paid at a lesser benefit. - Qualifying Life Event (to change insurance)
A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby) and gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
What is an Insurance Navigator?
An Insurance Navigator provides free and unbiased help obtaining health coverage to residents of Chelan, Douglas, Grant, and Okanogan county, regardless where the patient seeks care. The Navigator assists their clients in-person and on the phone through the enrollment process for programs such as:
Apple Health (Medicaid)
Free or low-cost health insurance for those who qualify; ongoing enrollment period
Qualified Health Plans (QHPs)
Purchased plans offered through the Washington Health Benefit Exchange; subject to open enrollment or a qualifying life event
A Navigator may also help clients with PCP and plan changes, serve as referral resource for self-paying patients of Confluence Health, as well as screen potential applicants for Charity Care (CCP).
Financial Navigator Locations and Contact Information:
Walk-ins are welcome, appointments are encouraged!
Okanogan Residents will be assisted by phone/scheduled appointment, and a Navigator will gladly travel up North as long conditions allow.
Confluence Health Hospital | Mares Campus is one of nine public health agencies, regional health networks, and community organizations selected to provide free support to individuals and families signing up for coverage through Washington Healthplanfinder.
Please know Confluence Health Hospital | Mares Campus is here to help individuals and families throughout NCW as a local and trusted resource in a dignified, compassionate, and respectful manner ensuring the communities we serve receive sound guidance in navigating their health coverage options. Confluence Health Hospital | Mares Campus could not do this without the partnership and collaboration of likewise agencies and organizations throughout Chelan, Douglas, Grant and Okanogan Counties such as Columbia Valley Community Health, Moses Lake Community Health, Family Health Centers, and many others.
Additionally, individuals and families needing to connect with a navigator before or during the open enrollment period can find help in their area by clicking the “Customer Support” link on www.wahealthplanfinder.org. Additional support can be found by calling Washington Healthplanfinder’s Customer Support Network at 1.855.923.4633.
Reminders: Enrollment is offered year-round to individuals and families through Washington Apple Health (Medicaid). Customers enrolled in Apple Health will receive a notice 60 days before the month in which they enrolled in or renewed their coverage last year.
About Washington Healthplanfinder
Washington Healthplanfinder is an online marketplace for individuals, families and small businesses in Washington to compare and enroll in health insurance coverage and gain access to tax credits, reduced cost sharing and public programs such as Medicaid. The next open enrollment period for Washington Healthplanfinder is set to begin on Nov. 1.
About Washington Apple Health
In Washington, Medicaid is called Washington Apple Health. Coverage is free and available year-round for those who qualify. Since the Affordable Care Act launched in October 2013, more people have access to preventive care, like cancer screenings, treatment for diabetes and high blood pressure, and many other health care services they need to stay healthy. Apple Health clients enroll and renew online using Washington Healthplanfinder. Apple Health is administered by the Washington State Health Care Authority: www.hca.wa.gov.
Find Your Expert Provider
Explore our full network of physicians, specialists and care teams — filter by service, language, location and insurance to find the right match for you.