WS Insurance Information


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WS Insurance Information:

  • WS will check eligibility and benefits, submit claims, and follow up on claims for in network insurance only. We do not offer this service for out of network insurance.

  • Insurance does not permit for dates of service to be backdated. Therefore, we are not able to submit claims for dates of service prior to a clinical associate completing the credentialing process.

General Insurance Information:

Most clients do not understand the complexity of their insurance benefits and the insurance billing process. To help provide you with information to be an informed consumer we included a general description of the insurance remuneration process.

1. The first step in the insurance process begins when a client provides WS with his or her insurance information, demographic information, guarantor information, and subscriber information. It is imperative that all of this information is provided in a timely manner and is completely accurate. WS also has to have permission from the client to use this information to check insurance benefits and submit claims.

2. WS will take the information provided, contact the insurance company, and check the client’s eligibility and benefits.

3. It is important to understand that all insurance companies state the following disclaimer when conducting an eligibility and benefits check, “A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service.” This disclaimer means that insurance companies will provide a quote of insurance benefits that may or may not be accurate and up-to-date. We find that approximately 60% of initial benefits checks contain inaccuracies. To try and circumvent this common problem WS checks eligibility and benefits using multiple sources to try and validate the information we receive. We find that adding redundancy to our processes helps to reduce the problems of inaccurate insurance benefits checks by approximately 20%. We advise our clients to consider all eligibility and benefits checks as a soft quote of benefits until the first three dates of service complete the insurance remuneration cycle.

4. When a client receives clinical services the client’s credit card on file is charged based on the eligibility and benefits check WS received from his or her insurance. WS will electronically submit an insurance claim to the client’s insurance company.

5. The insurance company will process the claim. This claim will either be rejected, denied, or accepted. If the claim is rejected then WS will follow-up, edit the claim, and resubmit the claim. The most common reason a claim is rejected is because the client provided incorrect information to the provider. If the claim is denied then WS will follow-up, edit the claim, and resubmit the claim. WS receives very few claims denials. The most common claims denial reason is because the client no longer has insurance and his or her insurance terminated. If the claim is accepted then the insurance company will process the claim based on the client’s benefits as per the policy provisions in the contract.

6. The insurance company will send electronic remittance advice (ERA) to WS regarding how the claim has been processed and what the payment provisions of the policy are as per the insurance contract. Clients receive an explanation of benefits (EOB) that contains the same information that WS received via ERA. Clients may receive an EOB via mail, email, or through their insurance provider portal.

7. If the insurance benefits on the policy include payment from the insurance company then WS will receive the payment. If the insurance benefits on the policy do not include payment from the insurance company then the ERA and EOB will show the total balance for charges as patient responsibility. For example, if a client has a deductible on his or her policy and the deductible has not been met then the insurance will not pay and the patient responsibility is for the balance on the account. Once the claim has been processed and WS receives the ERA and payment, if applicable, then the claim has completed the remuneration cycle.

General Insurance Information Q & A:

1. How Does Insurance Work?

Please review the following resources:

How Insurance Works (YouTube Video) 6 Minutes

Health Insurance Explained - The YouToons Have It Covered (YouTube Video) 6 Minutes

Understanding Your Insurance Costs (YouTube Video) 5 Minutes

The Health Insurance Claims Process (YouTube Video) 7 Minutes

The Basics of Medical Billing - Article

Medical Billing & Coding Vocabulary (Video) 7 Minutes

Medical Billing & Coding : The Medical Billing Process (Video) 11 Minutes

Medical Billing & Coding : Possible Errors & Problems (Video) 7 Minutes

The APA Guide To Mental health & Substance Abuse Parity (Equality) In Health Insurance (Article)

Mental Health America (MHA) : How Insurance Works (Booklet)

Mental Health Insurance (MHA) : How To Use Insurance (Booklet)

Mental Health America (MHA) : Deductibles, Copays, & Coinsurance Information (Booklet)

Mental Health America (MHA) : Paying For Care

State Laws Mandating or Regulating Mental Health Insurance Benefits

2. How Do I Check My Insurance Benefits?

  • There are two main ways you can check your insurance benefits.

  • The first is to call the member services 800 number on your insurance card. Follow the prompts necessary to obtain your outpatient mental health and substance abuse benefits. If you are unfamiliar with insurance basics it may be helpful to call and speak with member services to obtain this information so you can ask questions regarding your eligibility and benefits.

  • The second method is to go online to your insurance company member portal. If you have not used your member portal before then you will need to set up and activate your portal prior to obtaining your eligibility and benefits.

  • For additional information please review the following resources: Wiki How - Verify health Insurance Benefits , & Complete List of Diagnosis Codes By DSM-5 Disorder .

3. What information do I need to check my eligibility and benefits with my insurance company?

  • In most situations, the following information is needed to check your own insurance eligibility and benefits:  The current insurance card which will have the client’s Member ID and Group Number, the phone number for member services if you are calling your insurance company, the client’s date of birth, the client’s address, and the client’s phone number.

  • If you are not the client and you are calling for someone else then you will have to be someone that is permitted to receive this information. For example, a parent or guardian may call to obtain insurance, however; a spouse, friend, significant other etc may not check your benefits for you.

  • You may also need the following information for the subscriber on the insurance policy: The subscriber’s name, the subscriber’s date of birth, the subscriber’s address, the subscriber’s phone number, and in some circumstances you may need the subscriber’s social security number.

  • Also, it may be helpful to know the insurance CPT Codes that Wellness Solutions uses to submit insurance claims. The CPT Code for an Initial Psychiatric Evaluation is 90791. The CPT Code for Individual Psychotherapy 45 Minutes is 90834. These are the two most common CPT Codes used by Wellness Solutions.

  • If you are checking your insurance eligibility and benefits with your insurance company then you will be asked what service you are seeking. These two codes are used for individual outpatient counseling and psychotherapy for mental health and substance abuse.

  • The insurance company may ask for a diagnosis code. If you have not received any services and this benefits check is prior to your first session then it is completely acceptable to inform your insurance that you do not have one at this time. The insurance company is still able to check your benefits. A diagnosis code is a specific unique code number assigned to each diagnosis. In psychology all of the diagnosis and diagnosis codes are contained in “The Bible of Psychological Disorders” which is called The Diagnosis Statistical Manual - V (DSM-V). A diagnosis code is required to submit claims to insurance companies.

  • For additional information please review the following resources: Wikipedia - Diagnosis Codes , Wikipedia - DSM V , & Complete List of Diagnosis Codes By DSM-5 Disorder

  • It is notable that there are some diagnosis codes that insurance will not reimburse for, however; we are well aware of the excluded diagnosis for most insurance companies and that does not preclude you from checking your own benefits.

4. What is a subscriber for an insurance policy?

Subscriber: The subscriber is the person who you are able to obtain insurance through. For example, if you are an adult who is on your mom’s policy because your mom’s work offers insurance benefits then your mom is the subscriber on the insurance policy.

5. I have XYZ Insurance what are my insurance benefits?

  • If only it was that easy! Every insurance company will sell different types of insurance policies which will have thousands of different eligibility, benefits, and policy provisions.

  • We often are asked questions like, “I have XYZ insurance, how much is my copay,” or other similar questions. We are not able to answer because checking eligibility and benefits requires detailed information that must be verified with an insurance company. We are also not able to answer this question because one insurance company has so many insurance plans.

6. Can you check my insurance benefits prior to me signing the intake documents and scheduling an appointment?

  • Quite simply we cannot do that.

  • To check eligibility and benefits we must receive detailed information about your insurance plan and policy, the client’s personal information, and the subscriber’s information.

  • We are also required to obtain written permission to check your benefits. Therefore, we cannot check insurance benefits for any individual seeking treatment prior to receiving all intake documents signed and scheduling an appointment with a clinician.

  • Also, checking insurance benefits and receiving information about your insurance benefits is the responsibility of your insurance company. You pay your insurance company to manage your insurance benefits and to provide you with information about your insurance. Providers check insurance benefits for billing purposes. Insurance companies are the go to resource for their members to receiving information about the members’ benefits.

7. I do not want to commit to signing any documents or scheduling an appointment if I do not know my financial responsibility for treatment. How do I know if I can commit to treatment if you cannot check my benefits prior to scheduling an appointment?

  • Good questions. We strongly encourage everyone to be empowered and informed consumers for the services they seek.

  • We believe knowledge is power and making sure you are making the best decision possible includes evaluating all of your options, comparing these options to your needs, and understanding one’s personal responsibilities.

  • We recommend that you contact your insurance company and request your outpatient mental health and substance abuse benefits.

  • You can also check to see if both Wellness Solutions and the clinician you are interested in scheduling an appointment with are in network providers or out of network providers with your insurance company.

8. What information do I need to verify if Wellness Solutions and my Clinical Associate are in network providers?

The following information may be requested by your insurance company to check the network status of Wellness solutions and your Clinical Associate:

  • Wellness Solutions, LLC Address: 26310 Oak Ridge Drive, Suite 5, The Woodlands, Texas 77380

  • Wellness Solutions, LLC Phone Number: 713-893-3989

  • Wellness Solutions, LLC Fax Number: 888-502-1506

  • Wellness Solutions, LLC NPI: 1922375484

  • Wellness Solutions, LLC Tax ID: 800221405

9. What is an allowable?

Charge: The complete fee a provider charges for a specific service.

Allowable: The amount a provider agrees to accept as a charge in order to be an in network provider with an insurance company. When a provider credentials with an insurance company the provider agrees to reduce his or her fees from the standard charge amount to the allowable amount. The allowable amount is then the fee used to calculate the client’s coinsurance.

  • The allowable for services changes between insurance policies. The allowable for one policy can vary for another policy by the same insurance company. Also, allowables differ significantly between insurance companies.

  • One reason we recommend considering an eligibility and benefits check to be a soft estimate until the first three claims complete the remuneration process is because most insurance companies provide incorrect information regarding the allowable for a policy.

  • Many providers choose to credential with insurance companies or not based on the average allowable set forth by the insurance company which a provider is required to accept to credential as in network.

Adjustment: The difference between the charged amount and the allowable is called the adjustment. This is the amount a fee the provider writes off in order to be considered an in network provider with insurance.

  • For example, if the charge amount for a service is $100.00 and the allowable for the service is $60.00 then the adjustment for the service is $40.00.

10. What is a deductible?

Deductible: The amount a client will pay prior to his or her insurance policy benefits activating. Deductible amounts and how deductibles work vary greatly between policies.

Individual Deductible: The deductible amount for each individual covered by an insurance policy.

Family Deductible: The deductible amount for every member covered by an insurance policy. If the family deductible has been met then the individual deductible in most policies no longer needs to be met.

  • For most insurance policies, the client must meet the amount of the deductible and then his or her copay or coinsurance will then be the amount paid for each session. For these policies, the client pays the full amount of the allowable for each session until the deductible is met.

  • For some insurance policies, the client will pay the copay or coinsurance which will go toward a deductible.

  • Client payments that go towards deductibles are not calculated on a dollar to dollar amount. Every insurance calculates the amount towards deductible differently.

11. What is the difference between a copay and coinsurance?

  • This is a very common question and there is a big difference between these two types of policies.

Copay:  A flat fee the client pays to the provider for service he or she receives. For example, if a client has a copay of $30.00 per session then he or she will pay that fee for each session.

Coinsurance: A fee the client pays to the provider that is a percentage of the allowable for the service her or she receives. For example, if a client has a coinsurance of 10% and the allowable for the service is $60.00 then the client is responsible to pay $6.00 per session.

12. What is an out of pocket (OOP) amount?

Out of Pocket: The maximum amount of money a client will pay towards his or her services. A client with an insurance policy with an out of pocket max amount of $2,500.00 will pay this amount and once it is met than he or she will pay $0.00 for services. This is also called a stop loss amount.

Individual Out of Pocket: The amount a client will pay individually towards services based on his or her policy. Once the individual OOP is met than the individual on the policy will pay $0.00 for services for the remainder of the benefit calendar year.

Family Out of Pocket: The amount an entire family on a policy will pay towards services. Once the family OOP is met than the family on the policy will pay $0.00 for services for the remainder of the benefit calendar year.

13. What is an insurance carve out?

  • Mental health and substance abuse benefits are often “carved out” to another insurance company. This means that the company on your insurance card which is the insurance company medical insurance is through is a completely different insurance company providing mental health and substance abuse benefits.

  • Mental health and substance abuse benefit carve outs are the most significant reason eligibility and benefits information is provided incorrectly. Eligibility and benefits checks do not give complete transparency and accuracy regarding mental health and substance abuse benefit carve outs.

  • This situation also provides significant challenges for a coordination of benefits (COB) problem. A COB problem with claims may occur because some insurance carve outs direct providers to send claims to the primary or medical insurance provider and some insurance carve outs direct provider to send claims to the carved out insurance company directly. If the primary or medical insurance fails to send the claim to the carved out insurance then claims can get incorrectly processed or remunerated. Equally as problematic is that insurance carve outs often have entirely different insurance information such as different member identification numbers and different group numbers. Therefore, when providers call the insurance carve out to obtain eligibility and benefits information the insurance company is unable to locate the client in their system. Insurance carve outs are a consistent confounding difficulty with mental health and substance abuse insurance billing.

14. What is balance billing?

  • Balance Billing is illegal and in violation of contractual agreements for providers who are in network with a client’s insurance company.

  • Balance Billing is legal and acceptable business practice for providers who are out of network with a client’s insurance company.

  • Balance Billing is when the provider charges the client for the cost of the adjustment of a charged service.

  • For Example, if a charge for a service is $100.00, the copay is $30.00, the adjustment is $40.00, the insurance pays out $30.00 and the provider sends a bill to the client for the adjusted amount of $40.00 then the charge to the client for $40.00 is balance billing.

15. Can a provider waive a copay or reduce their fee for a deductible amount?

  • It is illegal and against contractual agreements for an in network provider to waive or reduce a copay.

  • It is illegal and against contractual agreements for an in network provider to waive or reduce a fee for a deductible amount.

  • An out of network provider may charge whatever her or she chooses for the services they provide and in most circumstances there are no regulations or restrictions.

16. What is the average amount of time that it takes for an insurance claim to complete the remuneration cycle?

  • The average amount of time it takes for an insurance claim to complete the remuneration cycle is between 14-30 days. Insurance companies vary on the average turn-around-time between the date a claim is submitted to them electronically and the claim is processed completely.

17. If my insurance denied payment for a claim who is responsible for the balance on the account?

  • If insurance denies coverage on any claim the balance will be billed to the client's account.

18. Can I request that a change to my credit card be moved to another day?

  • Payment of fees is expected at the time services are rendered. It is the client's responsibility to know and understand his or her personal financial business including insurance policy provisions, eligibility, and benefits.

19. Are providers required to submit insurance claims to my insurance company?

  • Wellness Solutions, LLC will check a client's benefits and submit this information to insurance as a courtesy. Submission of claims to insurance is not a requirement, as such, clients will be responsible for all fees not covered through insurance for denied claims and incorrect explanation of benefits.

20. Insurance Examples:

Example 1: A client’s eligibility and benefits check is quotes as follows:

Individual Deductible Amount:  $2,500.00

Individual Deductible Met to Date:  $1,520.00 (Not Met)

Family Deductible Amount:  $5,000.00

Family Deductible Met to Date:  $5,000.00 (Met)

Copay:  $30.00

Individual Out of Pocket Amount:  $10,000.00

Individual Out of Pocket Met to Date: $1,350.00 (Not Met)

Family Out of Pocket Amount:   $20,000.00

Family Out of Pocket Met to Date: $15,000.00 (Not Met)

Charge for Service:  $100.00

Allowable for Service: $60.00

The Amount Paid Per Session: $30.00

Explanation of Example 1: The client was paying the allowable amount of $60.00 per session until his or her family deductible was met. Once the family deductible was met then the client began to pay the copay for the service which is $30.00 per session. The client will pay $30.00 per session until the individual or family out of pocket is met. Once the individual or family out of pocket is met then the client will pay $0.00 per session for the remainder of the calendar year.

Example 2:  A client’s eligibility and benefits check is quotes as follows:

Individual Deductible Amount:  $2,500.00

Individual Deductible Met to Date:  $2,500.00 (Met)

Family Deductible Amount:  $5,000.00

Family Deductible Met to Date:  $3,250.00 ( Not Met)

Coinsurance:  $10%

Individual Out of Pocket Amount:  $10,000.00

Individual Out of Pocket Met to Date: $1,350.00 (Not Met)

Family Out of Pocket Amount:   $20,000.00

Family Out of Pocket Met to Date: $15,000.00 (Not Met)

Charge for Service:  $100.00

Allowable for Service: $60.00

The Amount Paid Per Session: $6.00

Explanation of Example 2: The client was paying the allowable amount of $60.00 per session until his or her individual deductible was met. Once the deductible was met then the client began to pay 10% of the allowable amount which is $6.00 per session. The client will pay $6.00 per session until his or her individual or family out of pocket is met. Once the individual or family out of pocket is met then the client will pay $0.00 per session for the remainder of the calendar year.


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