CLAIM PROCESSING

Parents have a lot to deal with during the course of a pregnancy. Understanding the claim process can, the timeline, and the numbers can help alleviate financial stress

A note about In-Network Exceptions:

Once upon a time, in-network exceptions were looked to as the golden ticket for homebirths. The landscape has shifted– these are no longer as readily granted. What’s more, the amount paid with these exceptions is often lower than what you would receive by using your out of network benefits. Together, we’ll find the best route for you.

A note about Deductibles and Coinsurance

Since the launch of the Affordable Care Act, nearly all plans have been structured to include out of pocket costs in the form of deductibles and coinsurance.

GENERAL CLAIM INFORMATION

In most cases, a bill goes to insurance after you deliver. From the time of submission the claim will take around 30 days to process, although it can easily take over 60.  We will keep you informed – and your insurance company may send you an Explanation of Benefits (or an EOB). You may even see a denial.

If your midwife is out of network, odds are the first submission will get denied – don’t worry! We’re expecting this.

Send a copy of the EOB to your midwife or directly to us. And relax. We’re just getting started. 

Blue Sky Global Claim

Below is an example of a common insurance package. In this example, the plan allows the midwife’s full fee; you have a low deductible and low coinsurance.

SAMPLE CLAIM 1   •    $10,000 Claim   •   for ‘global maternity care’*  •   standard billing

Explanation: For the purposes of keeping it simple, let’s assume this is your very first claim for the calendar year.

 An $10,000 claim is sent to your plan – this is your midwifes full fee. Let’s say that your plan allows the full charges billed.

Will they pay that full amount? No. They’ll first subtract your deductible ($1,000) from their payment.  Next, they’ll take away the coinsurance (20%). The combined deductible and coinsurance will comprise your payment to your midwife. Your insurance will pay the rest.

 • Note: If your plan allows less than the full charge, your payment will be proportionally more, with insurance paying proportionally less.

*Unlike most medical services where each visit you have is billed at the time of the visit, maternity care is often billed to insurance as a bundled service after delivery. This type of billing is called ‘global billing’ and the most commonly used code for reporting service in this way is called ‘global maternity care’ which includes prenatal, delivery and postpartum care all under one procedure code 59400 and billed using your baby’s delivery date. The fee billed to insurance is then the global fee.

Per Visit or Set of Visits Claim

SAMPLE CLAIM 2   •   $700 Claim   •   for 3 visits   •    standard billing

ere is a sample of a claim for 3 visits, to show how, even with prior authorization, a claim may still not result in payment.

Explanation: Again, to keep it simple, this claims has 3 visits for a total charge of $700.

In this example, you have the same Deductible and Coinsurance as the last example.

Let’s assume they grant us the maximum allowable amount for each of the three lines we’ve billed.

 The allowed amount is $700 – but your Deductible is $1,000. You’ve chipped away the majority of your deductible. Future covered services will begin to result in payment. This round, however, is on you.