Pediatric Surgery
Insurance FAQs

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Insurance for Pediatric Surgery - Frequently Asked Questions

The glossary below defines many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan or health insurance policy. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any case, the policy or plan governs. 

(See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) 

If you have additional insurance related questions that aren’t answered in our frequently asked questions section, please email: PedSurgeryFinancialTeam@cchmc.org.

Glossary

This is the maximum amount the plan will pay for a covered health care service. May also be called "eligible expense", "payment allowance", or "negotiated rate" depending on your insurance company.

A request to your health insurer or plan to review a decision that denies a benefit or payment (either in whole or in part).

Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You generally pay coinsurance plus any deductibles you owe.

A fixed amount (for example, $35) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Yearly amount set as the most each individual or family can be required to pay in cost sharing during the plan year for covered services. An amount you could owe for covered health care services before your plan begins to pay. An overall deductible applies to all covered items and services. A plan with an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles. (For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible.)

Health care services that your plan doesn’t pay for or cover. Patients and their families are responsible for the full cost of the services themselves if they choose to still receive care that is considered an exclusion from their plan.

An expression of dissatisfaction or a complaint that you communicate to your health insurer or plan. A Grievance occurs after an appeal has been completed and also denied.

Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, including habilitation, and that meet accepted standards of medicine.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
The facilities, providers and suppliers your health insurer or plan are not contracted with your insurance. This may mean that you are responsible for a higher deductible or out of pocket cost, or your plan won’t pay for anything and you are responsible for the cost to use providers who are out of network. In some cases, we can try to get an insurance company to allow us to see you on a short term basis and cover the care at an in network rate, but there is no guarantee that insurance companies will agree to this. 
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
A written order from your primary care provider for you to see a specialist or get certain health care services. In many health maintenance organizations (HMOs), you need to get a referral before you can get health care services from anyone except your primary care provider. If you don’t get a referral first, the plan may not pay for the services.
A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.

Frequently Asked Questions

Cincinnati Children's accepts most commercial insurances such as Humana, Anthem BCBS, United Health Care, Aetna and Cigna plans. PPO plans are usually the insurance plans most likely to be able to come, some HMO plans may need a referral to come to Cincinnati Children's. Please contact your insurance plan to find out if Cincinnati Children's is in network with your plan. 

Exchange plans may require a referral, please have your PCP or Referring Surgeon to contact the exchange plan to refer you to our department. We do not participate in many plans. Please check if we are in your network.

We verify your insurance, network and benefit coverage to come to our Colorectal and Fetal department only. Once that is completed, your care team is notified that services can be scheduled for your child. This is typically a fairly quick process that takes only a few days to accomplish.

The length of time it takes for Medicaid plans varies, we have to first register our surgeon as a provider with your state. This is unfortunately a lengthy process. Then we obtain approval for your child to receive services out of state and notify your care team that your child can be scheduled for services. While this process is lengthy, we work hard to get approval for your child. 
If you have a commercial insurance, the cost of procedures varies because they have contracts with each insurance company. You can contact the insurance company and find out what your deductible and out of pocket maximum is, the total cost of your child’s care shouldn’t be more than the out of pocket maximum, unless you have co-payments for office visits. If you are uninsured, we will work with you on the total cost of all services. 

Insurance companies sometimes allow a few days in the hospital to start. Once the number of days the insurance company said your child can be in the hospital has passed we will get extensions, day by day, until your child is ready to go back home.

If you insurance denied the surgery, we will file an appeal to try to get the insurance company to reconsider. Sometimes the insurance company wants to speak to our surgeon directly, we will submit documents again if there is no exclusion. If the insurance company denies the need for surgery again, your family can file a grievance with the insurance company.

If you received a bill and have questions, contact our Billing Customer Service.
If you received a bill and want to make payment arrangements visit our Financial Assistance page.

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