Insurance Information
Insurance/Claims
Information
We can help. Give us a call
at (800) 964-1493.
Given the intensity of treatment,
length of stay, high staff-to-patient
ratios, and small number
of patients treated at any
one time (6 patients maximum)
some insurance coverage is
usually necessary to offset
direct costs to the patient.
Neither MediCare nor Medicaid
have adequate coverage for
in-patient pain rehabilitation
services at St. Helena Hospital
or Pacifica.
Some private insurance may
sometimes cover aspects of
both in-patient and residential
out-patient pain management
services but careful evaluation
of each separate insurance
plan is recommended. Some
personal costs are usually
anticipated.
With worker's compensation,
a direct referral from the "doctor
of record" in the eyes of
the insurance carrier is
usually necessary as a first
step. Then, after utilization
review evaluation and approval,
an evaluation appointment
can be confirmed. Patients
usually cannot secure their
own treatment without express
permission from the adjustor
or nurse case manager if
that treatment is to be paid
for by worker's compensation.
Click here
for information about how
we can help you with this
process.
Private Insurance:
In-patient services:
Professional services from doctors and others for pain management
services are usually paid at usual and customary rates depending
on your particular insurance plan. Separate from professional
fees are hospital fees for room, food, nurse, laboratory, pharmacy,
etc. If your insurance company certifies you for hospital admission
it will pay according to its normal rates of coverage minus
your deductible. This certification will be obtained by our office
after your evaluation. During hospitalization, separate charges
come from professional services and from hospital services.
Out-patient services:
As a residential out-patient your insurance may pay for some
or all of your professional services. Only in the most rare circumstances
will private insurance pay for your room, food, massage, and
exercise aspects of your program. If they deem your residential
out-patient treatment necessary and it is a normal part of your
coverage they will pay their portion of covered services (ie.,
physician, psychologist, physical therapist, etc.) minus any
remaining deductible you have. Thus, patients will likely only
be reimbursed by their insurance company for some and not all
of their treatment at Pacifica.
Usually our office can make a preliminary determination of
the extent of your insurance coverage if we have your diagnoses
and insurance information. We are happy to make the call
for you. Click
here if you would like to have us do that for you.
Worker's Compensation:
The requirements to receive treatment with Pacifica at St. Helena
Hospital under most worker's compensation programs is fairly
straight-forward. Your insurance will require the following:
- formal referral from
your doctor of record.
- verification from MD
that comprehensive in-patient
pain management services are
not available
in your region.
- permission from your
worker's compensation
adjustor.
- and possibly review and
authorization from a
utilization review committee.
- separate authorizations
are usually needed for
our evaluation and our
treatment.
Each state's worker's compensation rules and laws are different
but with your doctor's referral (usually written) to us for evaluation
and treatment with his reasons why will usually be enough to
get the process started. Click
here if you want us to help you get started.
The treatments we offer are billed separately for in-patient
and residential out-patient services. Our bills are submitted
under "professional services" codes.
Pre-authorization for hospital admission and out-patient services should
be obtained in advance by our office after completion of
your evaluation. In some instances, your insurance authorization
can be facilitated by you and your community physician prior
to coming to our evaluation.
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