Insurance Information

Navigating insurance during your medical care can be confusing. Avexa Healthcare is here to help.

Avexa accepts a wide variety of insurance plans, including:

• Select Federal Health Insurance Marketplace plans (also referred to as the "Exchange”). Avexa Healthcare participates in many public federal exchange plans. Call your insurance company to clarify your coverage and confirm if Avexa is on your plan.
• Major insurance plans (most private and employer-based plans)
• Medicare
• Medicare Advantage
• Kaiser Permanente
• Other federal and state government programs. These programs include Champus, Medicare and Medicaid. We will collect co-pays and deductibles at the time of service if you are covered by a government program. Please remember to bring your insurance card. When possible, we will also submit claims to your secondary insurance.

When you receive medical care, Avexa Healthcare will submit an insurance claim for you to one of our accepted insurance plans. Your insurance company will pay a contracted amount for the service.

You are responsible for paying any remaining amounts. Depending on the care you received, you will receive a consolidated statement that includes both facility fees from the hospital and professional fees from the doctor. This means that on a single statement, you will see charges for using the hospital’s operating room, recovery room, supplies, medication, room and board for inpatients, and technical services, as well as fees for examinations, readings, and other services performed by Avexa physicians and their staff.

If you can’t pay your entire amount due, please call 012-3456-789 to discuss flexible payment options. 

As a patient, you have several responsibilities. To register or check in for any exam or procedure, a picture ID is required.

Patient responsibilities related to your insurance company:

• Carry your insurance card with you at all times.
• Ensure your providers and health center participate with your insurance company.
• Understand your insurance benefits, including what your financial cost will be.

If you need specialty care:

• Contact your primary care provider for a referral (if your plan requires a referral).
• Delay scheduling an appointment until you receive approval.
• Return to your primary care provider before seeing a specialist again, if there is a limited number of specialty visits.

You may need prior approval from your insurance company for certain procedures or expensive prescription medications. This is called precertification or prior authorization. We will contact your insurance company to obtain this pre-approval.

Each insurance company takes a different amount of time for the precertification process. Most companies take between five and 14 days to approve a radiology test. Approval for surgery can take seven to 15 days. Contact our Precertification Department if you have questions about your insurance company’s process.

If your service isn’t medically urgent, we may reschedule it if we don’t receive approval within 48 hours of your procedure.  

Most managed care insurance companies, Health Maintenance Organizations (HMOs) or Point of Service (POS) plans require an extra step if you need specialty care. You may need a referral or authorization from your primary care provider.

An authorization/referral is not a guarantee of insurance payment. A member must be eligible at the time services are rendered. Services must be a covered health plan benefit and considered medically necessary according to your insurance plan's policies and procedures.

It is your responsibility to know whether your insurance company requires a referral. Let your primary care provider and staff know if your company needs a referral. Otherwise, you will be responsible for full payment if you receive services without a referral.

Avexa Healthcare determines the charges for your care based on the treatments you receive. Each insurance company decides how much it will reimburse for different medical services. Those rates vary widely. There are no usual or customary rates for specific services.

Payment is due at the time of service. We will submit a claim for you to any insurance company or third party that has a contract with us. You are responsible for any fees your insurance company doesn’t pay.  If there is any amount left after the balance for these services is resolved, the amount will be applied to any unresolved balances for other services provided to you by Avexa.

We reserve the right to use collection agencies or attorneys if all reasonable attempts to collect payment fail.

You may encounter unfamiliar words when dealing with your insurance. Here are a few you should know:

• Allowed amount: The negotiated rate your insurance company pays Avexa for a covered medical service.  Your insurance plan determines what portion of the allowed amount you’ll pay.
• Charges: The amount we bill you and/or your insurance company for services.
• Co-insurance: Your portion of the cost for a covered health care service. Typically, it is the percentage of the allowed amount after you meet your deductible.
• Co-payment: Your share of the cost of a medical service or item. Usually, you pay this during your doctor’s visit.
• Deductible: The amount you owe for covered health care services before your insurance plan starts to pay.
• Maximum out of pocket: The most you pay for covered health care services in a year. This includes deductibles, co-payments and co-insurance for in-network care. Once you reach your maximum, your insurance company pays 100% of covered benefit costs.
• Network: The doctors, hospitals and suppliers who contract with your insurance company. Before scheduling an appointment with us, please contact your insurance company to confirm we are in your network.
• Predetermination: Medical staff reviews your case to decide if a suggested treatment is correct, necessary and covered under your insurance plan. They make this decision before we schedule your care.
• Premium: The amount you pay for your insurance plan each month.