Pregnancy brings with it endless questions and many of them often revolve around insurance coverage and what is included and what isn’t. Each provider is different and each plan at those providers also varies. Some services are in-network with one but not the other or specific providers might be in-network for specific services but not others. There are co-pays, deductibles, codes, and acronyms.

Basically, it’s complicated.

The best place to learn what is covered and what benefits are available to you is often your company’s HR department. They’ll be able to explain the full picture and point you to additional benefits you have access to outside of your insurance (like a doula allowance). You can always call your insurance provider but it is often difficult for customer service reps to share a general overview of your coverage. 

As with all medical insurance coverage there are in-network and out-of-network providers for maternal health services. Most of Partum Health’s physical therapists, lactation consultants, behavior health professionals, nutritionists, and acupuncturists are in-network with BlueCross BlueShield PPO, United Healthcare PPO, Cigna, and Aetna in Illinois. Our behavior health professionals are in-network with United Healthcare and Aetna in Texas. We’ve created this guide to help you navigate some of the most common questions we get regarding out-of-network coverage, especially for our families in Texas.

Again, each individual insurance plan is different and coverage details vary but we’re here to help you figure it out!

You’ve heard of deductibles which refers to the specific amount of money a patient must pay out of pocket for certain services before insurance coverage kicks in. Most operate on an annual basis and there can be individual deductibles, family deductibles, and even service type deductibles (one specifically for physical therapy, for example).

Your plan might even have different deductibles for in-network services and out-of-network services. In-network is more straightforward, but for out-of-network services you can file claims against that deductible over the course of the year and when you reach the threshold, your insurance reimbursement will kick in at the predetermined ratio.

It’s about as clear as mud right? Keep going, this is important information for you as a patient!

Out-of-network services are often eligible for reimbursement so it is important to file claims to your insurance company. But how?

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Enter: The Superbill

A health insurance superbill is an invoice that a healthcare provider gives to a patient after a visit or medical service. You, as the patient, will pay out-of-pocket for the service at the time of the visit to out-of-network providers, then you can use the superbill to seek reimbursement from your insurance company.

The superbill will include all the relevant information your insurance company will need to process your claim.

• Company or Medical Office Info (in our case, it will say Partum Health Service Corporation)
• Service Provider Info (the name and address of the clinician you saw)
• Diagnosis information and reason for care
• CPT codes to categorize which services were rendered during the visit
• Total out-of-pocket amount paid by patient

Great, you’ve got your superbill. Now what?

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Time to get paid! (aka Insurance Reimbursement)

Your insurance provider will reimburse you for your out-of-pocket expenses according to your individual plan. Often, out-of-network services are tracked against a separate deductible than your in-network services. We recommend inquiring about those spending caps with your HR department and insurer before seeking care. 

If you want to know if specific services are covered please reach out to your Partum Care Team member for specific CPT codes to take to your insurer. We’re here to help make this process as smooth as possible. 

You’ll submit a separate superbill claim for each individual visit. Our superbills are available to our patients in the Partum Portal. Each insurance company has their own process for submitting claims. Sometimes it is an online portal, other times it is via mail. 

Once your superbill is submitted your insurance company will review the claim and determine what can be reimbursed according to your plan. If the services are covered, the insurance company reimburses you directly. The amount you receive is usually less than of the out-of-pocket amount you paid depending on your policy’s terms such as deductibles, co-payments, and out-of-network coverage limits. 

While you might not feel like you're staring into the crystal clear waters of the Caribbean, we hope this superbill primer helped you understand the process a little bit better. Questions about insurance, in-network coverage, co-pays, and out-of-pocket expenses are some of the most common questions our Care Team receives. You’re not alone, this is complicated and every family’s coverage is different. We are here to help, reach out to us today to learn more.