Insurance & Billing

As a service to our patients our office will verify health insurance benefits for each office visit. Please note that the responsible party for each patient is responsible to know his/her benefits before arriving for the appointment. Many times the information we obtain from your insurance company may be incorrect.

Our practice handles all claims and billing questions. Any accounts with outstanding balances greater than 60-days from the date of service will be subject to collection. We realize at times that there may be a financial hardship. Please communicate this with our billing staff and they will assist you.

Insurances Accepted

We accept all major insurance  plans. Please call us to to verify that we can handle your specific insurance coverage.

Health Insurance Terms

We have provided the information below to assist you with understanding the terminology used with health insurance plans.

Co-Insurance: This is a shared coverage between the insurance company and the patient once the deductible has been met. Some procedures are a shared cost between the insurance company and the patient. An example would be what is called an ”80/20 plan”, where the insurance pays 80% of the visit and the remaining 20% would be considered the patient’s responsibility. Some examples of procedures that may fall under a co-insurance are: circumcisions, strep screens, breathing treatments, urinalysis and other testing.

Coordination of Benefits: Many insurance plans will request information concerning other benefit coverage. This is called ”Coordination of Benefits” or COB. When the insurance company requests this information, the subscriber is responsible to contact the insurance company to review their benefit coverage. Claims are not paid until the subscriber contacts their insurance company. We inform our patients as claims are denied for COB and once the patient contacts their plan, the claim should be reprocessed for payment. Please note: All balances are dropped to the patient until the COB has been updated. Our office requires payment within 60 days from the date of service.

Co-Payment: A co-payment is a predetermined fee, in addition to what health insurance pays for health care services. Some insurance plans do not apply a co-payment for well visits. In partnering with our patients, we ask you to know whether or not your plan has a co-payment for all visits.

Deductible: The amount of money that must be paid by the patient each year before the medical insurance starts paying. Check with your insurance plan to see if you have a deductible. If your plan does have a deductible, please be prepared to pay at the time of service.

EOB (Explanation of Benefits): An explanation on what the insurance paid on your claim and what may remain as your responsibility.

Exclusions: Specific conditions for which an insurance company will not provide coverage.

Health Savings Account: This plan generally has a higher deductible and the patient pays for everything (except preventive care in some plans) up to that deductible, then all medical costs are covered at 100%. The premium for this type of insurance is generally lower than on a “traditional” co-pay plan. This plan offers a way to place pre-taxed dollars into an account to pay towards the deductible each year. Typically you can have the money roll over each year.

HMO (Health Maintenance Organization): This plan has a network of physician’s and hospitals contracted with your insurance plan. You must select a PCP that participates with your plan prior to making an appointment. Some HMO plans also have ”out of network” benefits. Typically the ”out of network” benefits have a higher out of pocket expense for you the consumer. It is your responsibility to know whether our not a doctor is in your network.

PPO Plan (Preferred Provider Organization): This plan operates much like an HMO plan, however you do not need to select a PCP and you will not need an authorization from your primary doctor to see a specialist. Typically a PPO plan will have ”in and out of network benefits”. It is your responsibility to know whether or not a doctor is in your network.

Pre-existing Condition: A health problem that existed before enrolling for health care coverage. Many plans may not pay for pre-existing conditions. Check with your plan for further direction.

Primary Care Physician: A Primary Care Physician or ”PCP” is a doctor selected by you and submitted to your insurance. Certain insurances require that a PCP be selected before the claims can be processed. Generally, PCPs have to be considered ”in-network” with your insurance in order for any claims to be paid. Please check with your plan to make sure you select an ”in-network” doctor.

Prior Authorization: A process required by an insurance company to determine certification of medical necessity. Authorizations may be required for things such as medication, testing and referrals to a specialist. Please note an authorization does not guarantee payment by the insurance company.

  • Pleasant Peds Care of Conyers

    1415 Milstead Rd, Suite C
    Conyers, GA 30012
    770-648-6620

  • Our Regular Office Hours

    Mon-Thu 8:30 am to 4:30 pm
    Fri 8:30 am to 12:00 pm

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