Insurance Plans & Benefits

Modern Family Medicine participates with most insurance plans, with limited exceptions. Each insurance plan has different benefit packages and regulations, and it is not possible for Modern Family Medicine to be familiar with all insurance details or verify benefits for each patient. Patients should understand their insurance benefits, including coverage for copays, deductibles, and co-insurance amounts. It is the patient’s responsibility to inform Modern Family Medicine staff about their insurance coverage for the services provided. Patients will be fully responsible for charges related to services that are not covered by their insurance policies.

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Patient Payment Agreement & Failure to Pay

Modern Family Medicine is a member of the Piedmont Healthcare Network, and unless otherwise specified, the insurance allowable fee for services is based on the Piedmont Healthcare Network fee schedule. Patients are responsible for keeping their accounts in good standing with Modern Family Medicine. If payment cannot be made and no special payment arrangement is in place, Modern Family Medicine may deny services or discontinue treatment.

Payment Methods

Modern Family Medicine accepts

Cash

MasterCard

American Express

Discover

Visa

Insured Patient Policy

At each visit, unless classified as a **Self-Pay Patient**, you must present an active insurance card. Modern Family Medicine will submit insurance claims for the services provided using CPT (Current Procedural Terminology) codes. Most insurance plans allow Modern Family Medicine to bill for laboratory and diagnostic services, with some exceptions. If an exception applies, billing will come directly from lab or another radiology facility.

Your insurance claim will include office visit codes, diagnostic testing, laboratory services, and any necessary vaccine administration.

Insurance Claim Processing / Explanation of Benefits (EOB):

An Explanation of Benefits (EOB) is a statement from your health insurance provider outlining coverage details and your financial responsibility. An EOB typically includes:

Service Details: Date of service, CPT code, provider name, and service description.
Provider Charges vs. Insurance Allowance: The amount billed versus what the insurer allows.
Patient Responsibility: Copays, deductibles, and co-insurance based on the patient’s policy.
Denied Claims Explanation: Includes reasons for denial and steps for appeal.

Key Insurance Terms

Amount Billed – The total charge submitted to your health plan.
Your Plan Discounts (Adjustments) – The portion of charges, you do not need to pay.
Amount Paid by Your Health Plan – The insurance-covered portion, minus copays, deductibles, or co-insurance.
Copay – A fixed amount paid for services (e.g., office visits, prescriptions).
Deductible – The amount you must pay annually before insurance covers additional costs.
Example: ** If your plan has a $2,000 deductible, you pay the first $2,000 in healthcare expenses before insurance takes effect.
Coinsurance– The percentage of covered costs you pay after meeting your deductible.
Example: If insurance covers 80%, you pay the remaining 20%.
Amount Not Covered – Services not included in your plan, exceeding maximum reimbursements, or lacking pre-authorization or listed primary care physician.
Your Total Responsibility – Your balance based on copays, deductibles, coinsurance, or non-covered services.

If you disagree with an insurance claim decision, contact your insurance provider to file an appeal. Coverage does not always mean full payment.

Annual Preventive Visits / Physicals:

Typically billed with preventive visit codes along with laboratory and vaccine administration codes.
Some screenings and diagnostic tests may not be considered preventive by your specific insurance plan.
If a chronic condition (e.g., hypertension, hypothyroidism) or an acute issue (e.g., upper respiratory infection) is addressed during the visit, an additional office visit code will be added to the claim, along with applicable non-preventive diagnostic testing.
Preventive visits are often covered 100% by insurance, but additional non-preventive services may require copays, co-insurance, or deductibles.

Patients are responsible for copays, deductibles, and co-insurance payments as determined by their insurance carrier, payable within 30 days of receiving a billing statement from Modern Family Medicine. Delinquent accounts will be transferred to a third-party collection’s agency, Transworld.

Once the insurance claim is processed, patients will receive an Explanation of Benefits (EOB) detailing coverage, payment, and patient responsibility. If you believe an error has been made, please contact your insurance carrier directly. Modern Family Medicine will only bill you for the amount determined by your insurance carrier.

If your insurance coverage changes, notify Modern Family Medicine immediately to avoid untimely claim denials. If incorrect or expired insurance information is provided, and a claim is denied due to timely filing restrictions, the patient is responsible for the full balance.

Most insurance plans cover Annual Preventive Visits / Physicals once per calendar year. However, some plans may require a full 12 months between visits. It is recommended that you check with your insurance provider to confirm coverage.

CPT codes for Annual Preventive Visits are typically covered at 100% by insurance carriers. However, additional preventive diagnostic tests (e.g., laboratory work, ECG) and non-preventive services (e.g., chronic disease management) may not be fully covered. Co-pays, co-insurance, deductibles, or other payments may apply based on your specific plan.

CPT Codes for Annual Preventive Visits:

New Patient	Established Patient	Age Group	Description
99385	99395	18 – 39 Years	– Age & gender-appropriate history
99386	99396	40-64 Years	Same as above
99387	99397	65+ Years	Same as above

Counseling
Risk factor reduction interventions
Ordering of appropriate immunizations, lab, and diagnostic procedures

Please verify with your insurance provider whether your Annual Preventive Visit is covered and if additional services may require out-of-pocket costs.

Self-Pay Patient Policy

Patients who choose not to use insurance for their medical care at Modern Family Medicine are considered Self-Pay Patients.

Before each visit, Self-Pay Patients will receive a cost estimate based on the visit type and complexity.
Payment must be made in full before the appointment, based on discounted Self-Pay rates.
If additional tests or treatments are required during the visit, additional charges may apply.