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Insurance Info

Skills on the Hill is committed to providing the highest quality of services while supporting families’ ability to access multiple funding resources. Please be advised that Skills on the Hill, LLC (SOTH) is a concierge therapeutic provider and each patient’s benefit coverage is not a guarantee of payment. Ultimately, all patients hold financial responsibility for the services they sign up to receive.

Skills on the Hill will submit claims to insurance for you as long as your insurance benefits cover the services provided. It is the patient/ guardian’s responsibility to provide updated insurance information when the plan changes. Patients always have the ability to choose to have a discounted self-pay rate in which claims are not submitted to the insurance. There are no guarantees of coverage, regardless of if a provider is considered “in-network” or “out of network”.

Skills on the Hill will obtain authorizations for therapy services (when required) and submit claims electronically to your insurance carrier on your behalf. If you do not have out-of-network benefits, and there is the option to request a GAP extension (see below), you are responsible for completing the process to obtain the GAP extension on your own before SOTH can file claims on your behalf.

Claim submissions to insurance will be timely and our billing department will consistently follow-up on any unpaid claim issues. After insurance reimbursement, your out-of-pocket expenses will never be higher than our current self-pay rates (see below).

If the deductible has not been met, your insurance will apply charges to your deductible and you will be responsible for the patient responsibility until the deductible is met. Skills on the Hill will provide you with a bill for this amount and then the credit on file will be processed automatically.

If the deductible has been met, we will file a claim and then review how the claim processed because all plans are different. If the insurance reimbursement is equal to/more than the self-pay rate for services (see fee list), you will have no patient responsibility and will not receive a bill.

If the insurance reimbursement is less than the self-pay rate for services, we will adjust the fee submitted to insurance to the self-pay rate and you will be responsible for the difference.

Please note you will never be responsible for paying more than the self-pay rate for a service. Please see our attached fee list for self-pay rates.

Carefirst Plans

CareFirst will reimburse the patient directly for services that have already occurred and patients with CareFirst will be expected to pay a minimum of self-pay fees at the time of service. After SOTH submits claims on the patient’s behalf directly to CareFirst and claims are processed, the patient will receive payment directly from CareFirst after the deductible has been met.

All (only) CareFirst clients are responsible for providing Skills on the Hill with any EOBs and/or Insurance Compensation payments provided directly to them for services rendered by Skills on the Hill. Failure to do so may result in cancellation or postponement of all services.

It is the patient’s responsibility to bring those statements and endorsed checks to our offices in a timely manner. Patients also have the option to deposit payments to their own bank accounts and then SOTH will charge their credit card for the amount paid by CareFirst.

Secondary Plans

SOTH will not submit to secondary insurance unless it is Tricare or HSCSN. If you have two insurance plans, one will be primary for all sessions. The insurance plans determine which plan is the primary insurance and which is the secondary insurance.

Let’s face it, sorting out insurance information on your own can be a hassle, especially if you’re trying to figure out if your child’s therapy treatment is covered. We are happy to provide our insurance billing services as a courtesy to families.

INSURANCE RESOURCE GUIDE

Definitions of Common Insurance Terms:

  • Out of Network: Skills on the Hill is considered out of network if we do not have a contract with your insurance plan provider. Please note that many insurance plans (ie. PPO and POS plans) do have out of network benefits, but verification is required.
  • In Network: Skills on the Hill is contracted with Tricare and HSCSN and is considered an “in-network” provider.
  • Deductible: The amount of money that you are responsible for paying for the year. Usually, the larger the deductible, the less you pay in premiums for an insurance policy.
  • Co-Insurance: The percentage of shared costs for a service that you are responsible for paying. This applies after you have met your deductible. For example, if you have paid your deductible and have a 20% co-insurance and receive a bill for $500 for services, then you would be responsible for $100.
  • Exclusion(s): A provision within a policy that eliminates coverage for certain or, in other words, your plan will not cover the service and it will not count towards your out-of-pocket maximum.
  • GAP Exception: A type of waiver that health insurance plans may approve to compensate for gaps in their network of contracted healthcare providers. This may allow patients to access “in-network” benefit coverage from an out-ofnetwork provider.
  • ICD-10 Code: ICD-10 stands for the International Classification of Diseases, Tenth Revision. ICD-10 is a standardized classification system of diagnosis codes that represent conditions and diseases, related health problems, signs and symptoms, and injuries that is used for medical claim reporting in all healthcare settings. ICD-10 codes depict the patient’s diagnoses that justify the services rendered as medically necessary.
  • CPT Codes: CPT stands for Current Procedural Terminology. CPT codes are numbers assigned to every task and service a healthcare provider provides to a patient. They are used by insurers to determine the amount of reimbursement that a healthcare provider will receive by an insurer for that service.
  • Authorization: The term authorization refers to the process of getting a medical service authorized from the insurance payer. The provider must apply for authorization before performing the service. Once approved the payer then provides the provider with an authorization number and document for the approved services.
  • HMO: HMO stands for Health Maintenance Organization. It is a type of insurance plan that usually limits coverage to care from medical providers who work for or contract with the HMO.
  • POS: POS stands for Point of Service. It is a type of plan in which you pay less if you use health care providers that belong to the plan’s network, but it does allow members to obtain services from out of network providers. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
  • PPO: PPO stands for Preferred Provider Organization (PPO). It is a type of plan that allows members to seek services outside of the network without first needing a referral. PPO plans offer more freedom to the members, but premiums are more expensive and out of network benefits are covered at a lower rate compared to in-network benefits.

Fee List:

1Fee List 2024

Fee List 2024