statement & fees

YOUR GUIDE TO UNDERSTANDING OUR BILLING PROCESS

We’re here to help you understand your bill or make payment arrangements. Get answers to common questions here, or contact us directly via the button below.


frequently asked questions about billing

Get answers about billing, claims, and authorizations.

What is my out-of-pocket cost for services?

Because insurance coverage varies, it is difficult to know your total out-of-pocket charges at the time of service. As routine practice, Edgewood collects all co-pay amounts at the time of service. Your payment method on file will be charged any remaining balance due once payment is received from your insurance company.

When will I receive a statement?

If you have insurance coverage, Edgewood will bill your insurance carrier shortly after you receive service. After a bill is sent to your insurance company, an EOB (Explanation of Benefits) is sent to your attention by your insurance carrier. After insurance is collected, you will receive an Edgewood statement outlining any amounts not covered by your carrier. This is a notification of your final amount due to Edgewood for your services and acts as a record of what was charged to your payment method on file. Any balances not collected will be listed on the statement and payment can be made online via credit card.

What is a claim?

In many ways, a claim is similar to a bill. It is a request to be paid for care. Sometimes people say “filing” or “submitting a claim.” These phrases mean the same thing.

You can see the status of your claims on your insurance website or by calling the customer service number for your insurance company. When a claim is approved, the insurance company will pay Edgewood. In most cases for in-network care, Edgewood will file claims for you and you’ll receive an explanation of benefits (EOB) from your insurance company. Your EOB is not a bill; it’s an explanation of how your claim was paid/processed.

What if I have questions about my claim?

If you have a behavioral health claim question, call your insurance company customer service at the number on your ID card. Some employer accounts have a dedicated customer service/claim line. If your benefit plan is set up this way, call that number for answers to your questions .

What is an explanation of benefits (EOB) and how does it relate to claims?

An explanation of benefits (EOB), is a document sent by your insurance company to show the costs and coverage related to your care. An EOB is not a bill. It is a document to help you understand how much each service costs, how much your plan will cover, and how much you will have to pay when you receive a bill. It includes: An item-by-item breakdown of your care visit with a claim details page displayed in an easy-to-read format; how much you paid toward your plan deductible (if applicable) and out-of-pocket limits; and a summary page with the amount saved and what you now owe.

How do I avoid claim denial?

Here are some tips to avoid denied claims: If you purchase coverage through a state or federal marketplace, pay your monthly premium on time; present your ID card when you receive services and make sure Edgewood has your current ID card information; verify the name and address on file with your insurance company matches the information on record with Edgewood; stay in-network (if required by plan); get prior authorization (if required by plan).

What is prior authorization?

Under your insurance plan, certain certain services may need approval from your health plan before they’re covered. The services requiring prior authorization are described in your plan documents, but as a courtesy, we will also call to verify coverage and gather information about your covered/uncovered services.

Certain medications may also need approval before they’re covered. These medications will only be covered if your doctor requests and receives approval from your health plan. Your insurance company will contact you and let you know if your drug coverage is approved or denied. The types of medications that typically need approval are: those that may be unsafe when combined with other medications; those that have lower-cost, equally effective alternatives available; those that should only be used for certain health conditions; and those that are often misused or abused.

How does the prior authorization process work?

For in-network policies, Edgewood will handle the process for you. If your plan is out-of-network, you are responsible for contacting your insurance company to obtain prior authorization, but we can help direct you to the correct information.

If you are unhappy with the results of your prior authorization, you can contact your insurance company to inquire. Or, we can discuss the option of prescribing a different treatment or medication. In some instances, your health plan will recommend an alternative treatment or medication before coverage is available for your doctor’s original prescription.