Insurance and Billing FAQs
Health insurance terms to know
What is authorization/preauthorization?
Authorization/preauthorization is when the insurance company is notified in advance of a surgery or hospital stay and is a required notification for most policies for the insurance company to pay for the care. The requirements can differ from policy to policy but the purpose of preauthorization is to notify the insurer or representative so they can determine if a hospitalization or surgery is medically necessary and how many days of hospitalization are authorized. If preauthorization is not obtained, the insurer will deny coverage for an otherwise covered service.
What is a benefit package?
What are carve outs?
What is co-insurance?
What is a co-payment?
What is a deductible?
What are definitions, benefits, limitations and exclusions?
What is a HMO?
Point-of-Service Plan or Point-of-Service Option (POS)
What is a PPO?
What is PSV?
Pediatric Specialists of Virginia (PSV) is a joint venture with Children’s National and Inova, two highly regarded and trusted medical centers, to provide world-class care for children and families. Through this physician group practice, Children’s National’s talented and nationally recognized teams will provide specialty services in shared settings, combining clinical strengths from both organizations and to make specialty care more convenient for families in northern Virginia and across the region. It offers pediatric Gastroenterology, Nephrology, Genetics, Hematology/Oncology and Orthopedics through this collaboration at three locations in the Fairfax, Va., area. If opting to use PSV, confirm with your insurance carrier whether your plan participates with this entity since it does not necessarily accept all the same insurances as Children’s National and Inova.
What to know before you visit the hospital
What insurance information should I have on hand when I visit the hospital?
- Name and telephone number of the child’s insurance company
- Policy holder’s name, social security number, place of employment and work phone number
- Policy and group numbers
- Name, address and phone number of your child’s referring physician
What if my child isn’t covered by insurance?
If you do not have health insurance, our financial counselors can help you determine if you are eligible to apply for Medical Assistance (Medicaid) and will help you through the process. We also can help you apply for our charity or financial assistance programs. Based on the first letter of your last name, the counselors can be reached at:
- A-K: 202-476-3326
- L-Z: 202-476-5505
Extended payment arrangements may be considered on an individual basis during your consultation. Please contact a customer service representative Monday through Friday, 9 a.m. to 4 p.m., at 301-572-3542. You also can visit the Financial Information Center located in Room 1820 on the first floor of the main hospital.
What do patients and parents/guardians have the responsibility to do?
- To provide, to the best of their knowledge, accurate and complete information about all matters relating to the child’s health
- To the extent allowed by law, to both formulate advance directives and expect hospital staff and practitioners who provide care will comply with these directives
- To be considerate of other patients and staff and to encourage the patient’s visitors to be considerate as well
- To pay for services provided, and/or provide necessary information to process insurance claims related to your child’s hospital and outpatient service bills
- To follow the treatment plan recommended by the practitioner and agreed upon for the patient’s care
What rights do I have if I am an adult patient?
What if I am the parent of an adult patient?
Who may sign paperwork and consent to evaluation and treatment for a child?
This information is provided to clarify who may sign paperwork and consent to evaluation and treatment for a child at Children’s National. If you have any questions about this information, please contact your provider.
- Biological parent. The biological parents are the child’s natural mother and father, i.e., the woman who gave birth to the child, and the man who fathered the pregnancy. Biological parents may sign all paperwork on the child’s behalf and may consent to evaluation and treatment unless a court has determined that the parent no longer has this right. By signing any paperwork at Children’s National, the biological parent certifies that there has been no court action which would prevent them from doing so.
- Adoptive parent. The adoptive parent is the parent who has been granted adoption of the child by court order. A copy of the court’s approval of the adoption must be provided to Children’s National in order for the adoptive parent to sign paperwork or consent to evaluation and treatment for the child.
- Foster parent. The foster parent may or may not be able to sign paperwork for the child, depending on which state and county in which the child lives. If you are the child’s foster parent, please contact the child’s social worker to clarify what you are permitted to sign for and to request documentation from the social worker indicating this. You will be required to present paperwork from the county establishing your ability to consent prior to the child being seen or treatment being given. Please also give the social worker’s name and phone number to the child’s provider so that we may contact the social worker directly if questions arise.
- Caregiver or other family member. The caregiver or other family member may not sign any paperwork on the child’s behalf, nor may they consent to evaluation or treatment unless they provide written authorization to do so signed by one of the biological parents. A copy of this authorization is enclosed for your use. This authorization will expire 60 days from the date the parent signs it.
- Parent requesting accommodation of a divorce decree. In an instance when the divorce decree changes either parent’s rights to consent to a child’s treatment, Children’s National needs to have a copy of that court decree. The court order may be brought the day of the surgery.
It is important that you bring any required paperwork referenced above to the child’s first appointment at Children’s National to avoid the need to cancel appointments or procedures.
Questions to ask the hospital about your bill
Why was my account placed with a collections agency?
Why was my bill sent to the wrong insurance?
What if I cannot pay my bill in full at the time of service?
Our financial counselors will work with you to set up a payment plan to resolve your outstanding balance. You may pay your bill with a check, money order, cash or credit card. We also accept payments online.
Payment plans for balances after insurance can be made through our Customer Service department Monday - Friday, 9 a.m. to 4 p.m. EST at 301-572-3542 or toll free at 800-787-0021.
How can I obtain an estimate of costs for my child's care?
Families can use this tool to enter insurance information and look up the estimated costs for appointments and medical procedures.
Good Faith Estimates
In accordance with the No Surprises Act, Children’s National can provide a Good Faith Estimate for scheduled visits for uninsured/self-pay patients or upon request.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.
You can request a Good Faith Estimate before your scheduled item or service. Please submit your request in writing at least three days in advance of the medical item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate for the services identified in the request, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
If I have a question about my bill, who can I contact?
Why are my out-of-pocket expenses based on my outpatient benefits?
What is the facility charge for outpatient visits?
The facility charge includes costs for running the facility, such as supplies, equipment, exam rooms, educational resources, counseling and staff. It is separate from the cost of the medical provider.
Charges are determined based on the type of visit and the hospital resources used during your child's visit. The exact facility charge cannot be calculated until after the medical services have been provided and your visit is finished.
- If you have Medicaid: These programs cover the full outpatient facility charge, so you will not have a balance to pay for the charge.
- If you have Children's Financial Assistance: This program will cover the outpatient facility charge based on the sliding scale up to 100 percent.
- If you have commercial insurance: Depending on your plan benefits and deductible amounts, you may be responsible for some portion of the clinic visit charge. Contact your insurance company to find out what your coverage is for outpatient hospital-based clinic charges.
Why do I receive a statement before the insurance has paid its portion?
Why do I receive two bills for each date of service?
What date of service does this bill cover?
Questions to ask your insurance provider
What types of services are generally covered by a group health insurance plan?
Generally, a comprehensive plan will include the full range of medical services. These may include:
- Professional services of doctors of medicine and osteopathy and other recognized medical practitioners
- Hospital charges for semiprivate room and board and other necessary services and supplies
- Surgical charges
- Services of registered nurses
- Home healthcare
- Physical therapy
- Anesthetics and their administration
- X-rays and other diagnostic laboratory procedures
- Oxygen and other gases and their administration
- Blood transfusions, including the cost of bloom when charged
- Drugs and medicines requiring a prescription
- Specified ambulance services
- Rental of durable mechanical equipment required for therapeutic use
- Artificial limbs and other prosthetic appliances, except replacement of such appliances
- Casts, splints, trusses, braces and crutches
What if your child has a pre-existing condition?
Insurers can impose only a 12-month waiting period for any preexisting condition that has been diagnosed or treated within the preceding six months. As long as you have maintained continuous coverage without a break of more than 63 days, your prior health insurance coverage will be credited toward the preexisting condition exclusion period.
If you have had group health coverage for at least one year and you change jobs and health plans, your new plan can't impose another preexisting condition exclusion period. If you have never been covered by an employer's group plan and you start a new job that offers such a plan, you may be subject to a 12-month preexisting condition waiting period. Federal law also makes it easier for you to get individual insurance under certain situations. You may, however, have to pay a higher premium for individual insurance if you have a preexisting condition. If you have not had coverage previously and you are unable to get insurance on your own, you should check with your state insurance commissioner to see if your state has a high-risk pool.
Does my surgery/hospital stay need preauthorization?
Does the insurance company require a second opinion?
What else does the insurance company require?
Most insurance companies require you to take certain steps before they will cover the cost of a surgical procedure for your child. Every parent should contact their insurance company to ask the following questions:
- Does the insurance company require a referral from the primary care physician?
- Does my insurance plan have a deductible?
- Does my insurance plan require a co-pay?
How can I pay for outpatient visits?
How can I pay for outpatient visits?
Medicaid covers the full outpatient facility charge, so you will not have a balance to pay for the charge. If you have Children’s National financial assistance, this program covers the charge based on a sliding scale up to 100 percent. If you have commercial insurance, the portion of what you will be responsible for depends upon your plan’s benefits and deductible amounts. Upon request payment plan options are available by contacting our Customer Service team Monday-Friday, 9 a.m. to 4 p.m. EST at 301-572-3542 or toll free at 800-787-0021 or e-mail [email protected].