Billing FAQ

Deductibles, copays, and coinsurance are different ways that your insurance requires you to pay for all or a part of your visit.

A copay is a flat fee that you pay at the time of your visit.

A deductible is the amount you need to pay each year before your insurance starts to share the cost of your visits.  For instance, if you have a $1000 deductible, you will pay all of your medical expenses until you reach $1000, and then your insurance kicks in.  Once you've met your deductible, your medical costs are covered according to your insurance plan for the rest of the year.

Co-insurance is when you and your insurance company share the cost of your medical care.  You each pay a percent of the visit For example you may pay 20% and your insurance pays 80%.  It usually starts once you have met your deductible for the year.

While most insurance plans pay for all of a well/preventive visit, some insurance companies will require you to pay for some of the services such as a hearing test or a developmental screen.  Coverage depends on your specific insurance plan.

Insurance companies require us to document and bill for everything that we do during a visit.  If other concerns or problems were discussed, evaluated, or treated during the same appointment as the well visit, your insurance may require you to pay a copay, deductible, or co-insurance for that portion of the visit. 

If the clinician addressed a new or ongoing concern or medical issue in addition to the routine exam, insurance requires that both services be coded and submitted. This reflects two distinct types of care provided during one appointment.

Here are some examples of common reasons why a sick visit would be billed on the same day as a well visit:

-Infections (your child is sick on the same day as the well visit and you have quesitons about it or an issue such as an ear infection is identified during the visit)

-Follow up for a chronic condition that we are managing (asthma, eczema, ADHD, anxiety, etc.)

-Discussions about behavior or development concerns (developmental delays, tantrums, sleep difficulties, toileting issues, behavior at home or school, depression, anxiety, etc.)

-Medication adjustments

-Growth concerns (poor weight gain, gaining too quickly, etc.)

-Concerns about your child's body (reflux, headaches, knee pain, abdominal pain, etc.)

-Something else was identified during the course of a visit that needs to be addressed such as a diaper rash, allergies, etc.

Appointments focused on monitoring a medical concern such as feeding issues, growth concerns, or medication management are considered problem‑focused visits under insurance guidelines rather than routine preventive care.

Primary care providers coordinate your child’s overall health over time, including reviewing specialist notes, managing chronic conditions, and monitoring long‑term concerns.

Some visits may include a billing code (G2211) that reflects this comprehensive oversight. Insurance coverage for this code varies by plan.

Here is our statement about the G2211 code:

Medical offices that take insurance get paid by “coding” what they do. These codes are designated by the Center for Medicaid and Medicare Services (CMS). A new code in 2024 – G2211 – has been created for primary care providers to indicate that they are following patients longitudinally and are committed to caring for the “whole patient” over time.

Unlike urgent cares and emergency rooms, South Philadelphia Pediatrics takes pride in offering this type of care and is excited that CMS is finally recognizing what we do. As such, we will be adding this “code” to all permitted visits, which now includes all patient encounters except for those designated as “Well Visits”.

Unfortunately, many insurance companies are not paying for all the services we provide, even if CMS says we need to document and “code” for it. Some carriers will completely deny payment. Others will pass the charge on to the patient. We are not happy with their position, and feel it is unfair both to us and to you. But, per our contracts with the insurance companies, we must continue to code for services as instructed. If you receive a bill for this code (typically $20 or less), we will not be able to waive the charge. Instead, we ask that you follow up with your insurance carrier directly for reimbursement.

We take great pride in providing your child with the highest quality of care possible. Documenting and coding appropriately for the services we provide is necessary for us to continue to serve our families in this way.

Some insurance plans require families to formally select a Primary Care Physician (PCP). If our office is not designated at the time of service, the claim may be denied.

If this occurs, please contact your insurance company to update your child’s PCP designation effective for the date of service. We can then resubmit the claim.

COB is the process by which insurance companies figure out whether a patient has more than one medical insurance plan and, if so, which is the primary plan.  

You may receive a letter from your insurance company asking you to update your Coordination of Benefits.  In this case, the policy holder for the insurance will need to contact the insurance company and let them know if the child is also covered under any other insurance plans.

Insurance companies will frequently refuse to pay for any visits until patients have updated their COB.  If the insurance denies a claim for this reason, we will let you know so you can get it fixed ASAP.  Once you have done so, we will resubmit the claim and the insurance should then pay.  If you fail to update your COB, you will have to pay for the visit.

Insurance companies often require time to officially add a newborn to a policy. Claims submitted before enrollment is complete may initially be denied but can typically be reprocessed once coverage is active.

Healthcare providers are legally required to submit claims using accurate diagnosis and procedure codes that reflect the care provided. Codes cannot be altered solely to obtain coverage.

If an error occurred, we are happy to review and correct it.

It is impossible for us to know the specifics of what your plan covers.  This is because each employer negotiates their own agreement with insurance companies, which means that even plans from the same company can differ in important ways.

For questions about deductibles, co‑insurance, preventive coverage, or frequency limits, please contact your insurance company directly using the phone number on your card.

Yes. We welcome families without insurance and can provide self‑pay pricing information upon request.

The total cost depends on the type of visit, services performed, and your specific insurance benefits. Because insurance determines final coverage after processing the claim, an exact amount is often not available at the time of the appointment.

If you have additional questions, please contact our billing team. We are committed to helping families understand their coverage and feel confident about their care.