Insurance Benefit Information and Billing
We are in-network with the following insurances:
Aetna
Anthem Blue Cross
Community Health Plan of WA (no new referrals)
Cigna
Coordinated Care (no new referrals)
First Choice Health
First Health/Coventry
Health Net
Lifewise WA
MODA
Molina (limited new referrals - physical therapy only)
PacificSource
Premera Blue Cross WA
Premera Lifewise OR
ProviderOne (no new referrals)
Regence Blue Shield of OR/WA
Tri-Care
United Healthcare (no new referrals)
Due to an unwillingness from the payors to negotiate new reimbursement rates we are no longer accepting any new referrals for: Molina, United Healthcare/UMR/Optum, CHPW, Coordinated Care, Wellpoint, Provider One
We are terminating our contracts with the following insurance companies as of 10/31/2025: Community Health Plan of Washington, Amerigroup, Wellpoint, Coordinated Care
Understanding My Benefits:
We understand that insurance is complicated. It is your responsibility to know your benefits as every insurance plan is different. The information below is intended to help inform you as a consumer and help you understand how to ask the right questions of your insurance company.
We do our best to verify your insurance and obtain authorization for therapy visits but we cannot guarantee that all services will be covered by every insurance. Insurance companies are increasing their requirements exponentially in an effort to reduce their costs and this limits our ability to see your children under your insurance coverage. Please contact your insurance company directly to see if our services are a covered benefit with your insurance plan. We are able to work with families with all insurances as an out-of-network provider or as private pay.
How Will My Benefits Be Processed?
Unfortunately we cannot predict how long it will take for your insurance company to process the claims we have submitted. We typically submit all claims within 14 days of the date of service however your insurance company may take 90 days or more to process your claim correctly.
We also do not control how your benefits will be processed by your insurance company. There are many categories that your insurance may use. Some of the common buckets insurance place therapy visits from our clinic are:
1. Rehabilitation vs Habilitation: Rehabilitation is regaining a lost skill. Habilitation is working to gain a new skill that was not lost. Many of our services are considered habilitative in nature by many payors, but not all payors. Rehabilitative services and habilitative services often have different requirements for prior authorizations, they have different benefit limits, and sometimes one category is excluded in your plan. Our office DOES NOT determine which category your insurance will process your payments prior to billing. This is something you can do by calling your insurance company and asking them to run a "TEST CLAIM" (details below).
2. Physical Health vs Mental Health: Depending on the diagnosis code that was used by your doctor and/or therapist when your child was referred for therapy services, your benefits may be processed under physical health benefits or mental health benefits. Our office has no control over which category will be used by your insurance company. Many plans have very different costs associated with physical health vs mental health benefits and you will be responsible for your portion of the costs. It is important to note that two different therapists (for example physical therapy vs speech therapy) may process in two different categories for the same child. The only way you can determine how these will process is for you to call your insurance company and run a "TEST CLAIM" (details below). Our office DOES NOT run test claims prior to treatment.
Test Claims:
We highly recommend you run a test claim to better understand what you will owe for therapy services based on your insurance company's benefits. Here are the steps to running a test claim:
1. Call our office and request the codes being used for your child's therapy so you can run a test claim.
** You will need to provide the ICD-10 code that our clinic is using to bill your services. This is the diagnosis code. Your child may have more than one code. Our office will provide you the codes and tell you the order they should be listed.
**You will need to provide the CPT codes that our clinic is using in therapy. These are the "procedures" being used in therapy. Our office will provide you with all the potential CPT codes that may be used in therapy.
2. Call the member number on your insurance card
3. Ask to run a TEST CLAIM for therapy services for your child. You will provide the codes you have received from our office. You want to find out:
* Limits to your therapy services
*Your associated costs (i.e. deductible, co-insurance, exclusions to services, etc). Remember, different services will be processed in different ways by your insurance and you may have very different expenses based on how the visits are processed.
Coordination of Benefits:
If your child is covered by more than one insurance you will need to determine which insurance is the primary insurance and which insurance is the secondary insurance. This is not something you get to pick. It is often associated the with the subscriber's birthdate. To coordinate your benefits effectively and not have any surprise bills you should do the following:
1. Make sure our office has accurate insurance information for ALL plans. If you do not provide the information to us we cannot bill your insurance. If mis-information or lack of information provided by you results in our office being unable to be reimbursed for services provided to you, these costs will be passed on to you.
2. Call your insurance companies to find out which insurance is your primary and your secondary insurance.
3. When your insurance company contacts you to update your information you must do so or your claims will be denied.
4. If your insurance company denies a claim under "Coordination of Benefits" as the reason, you as the member must call and correct this information with your insurance company or the financial responsibility of the visit will fall to you.
Deductibles, Co-Insurance, Co-Pays:
Deductible: This is the amount you have to pay before your insurance benefits pay their portion. If you have a $1000 deductible, you will have to pay this amount before your co-insurance kicks in.
Co-Insurance: This amount is typically a percentage of the amount that is billed to your insurance. For example, if your co-insurance is 20% this means that if you have a $100 bill your insurance will pay $80 and you will be required to pay $20. Typically you have to meet your deductible first and then your co-insurance benefit will start.
Co-Pays: This ia a flat amount that you are required to pay for a visit and your insurance pays the rest of the cost. For example, if you have a co-pay of $30 per visit, that is what you will owe for every visit completed. Usually, but not always, your deductible does not have to be met prior to paying co-pays.
Understanding My Bill and Making Payments:
We strive to make our billing and payment systems easy to use and transparent. Please call or email our office with further billing questions.
Understanding Your Invoices:
Our office sends a separate invoice for each month that claims are processed and charges are incurred. You will not receive an invoice if your insurance company has not yet processed your claims. If you receive more than one invoice it means you have more than one balance due.
Balances should be paid upon receipt. If you cannot pay your full balances please call our office to set up a payment plan. It is important that you set up a payment plan with our office to ensure that you can stay caught up with your incurred costs. Invoices that are 90 days past due from the original date of the invoice will be sent to collections even if you have made partial payments. If you have not set up an official payment plan with our office, the balance will be sent to collections. Therapy services will be suspended at that time. **We do not make individual phone calls to inform you that you have a past due balance**.
Making Payments:
You can pay your bill in a variety of ways.
1. Online patient portal: https://app.fusionwebclinic.com/portal/prismpediatrics. There is a 3% processing fee for all card payments (except HSA cards). You received a link to enroll when you started therapy services. If your link has expired you can call our office to receive a new invitation link.
2. Call our billing office: 360-800-6401. There is a 3% processing fee for all card payments (except HSA cards).
3. Mail a personal check.
4. Set up payment through your bank's online bill pay.
5. Pay in person via card (3% fee except HSA cards), check, or cash.
Aetna
Anthem Blue Cross
Community Health Plan of WA (no new referrals)
Cigna
Coordinated Care (no new referrals)
First Choice Health
First Health/Coventry
Health Net
Lifewise WA
MODA
Molina (limited new referrals - physical therapy only)
PacificSource
Premera Blue Cross WA
Premera Lifewise OR
ProviderOne (no new referrals)
Regence Blue Shield of OR/WA
Tri-Care
United Healthcare (no new referrals)
Due to an unwillingness from the payors to negotiate new reimbursement rates we are no longer accepting any new referrals for: Molina, United Healthcare/UMR/Optum, CHPW, Coordinated Care, Wellpoint, Provider One
We are terminating our contracts with the following insurance companies as of 10/31/2025: Community Health Plan of Washington, Amerigroup, Wellpoint, Coordinated Care
Understanding My Benefits:
We understand that insurance is complicated. It is your responsibility to know your benefits as every insurance plan is different. The information below is intended to help inform you as a consumer and help you understand how to ask the right questions of your insurance company.
We do our best to verify your insurance and obtain authorization for therapy visits but we cannot guarantee that all services will be covered by every insurance. Insurance companies are increasing their requirements exponentially in an effort to reduce their costs and this limits our ability to see your children under your insurance coverage. Please contact your insurance company directly to see if our services are a covered benefit with your insurance plan. We are able to work with families with all insurances as an out-of-network provider or as private pay.
How Will My Benefits Be Processed?
Unfortunately we cannot predict how long it will take for your insurance company to process the claims we have submitted. We typically submit all claims within 14 days of the date of service however your insurance company may take 90 days or more to process your claim correctly.
We also do not control how your benefits will be processed by your insurance company. There are many categories that your insurance may use. Some of the common buckets insurance place therapy visits from our clinic are:
1. Rehabilitation vs Habilitation: Rehabilitation is regaining a lost skill. Habilitation is working to gain a new skill that was not lost. Many of our services are considered habilitative in nature by many payors, but not all payors. Rehabilitative services and habilitative services often have different requirements for prior authorizations, they have different benefit limits, and sometimes one category is excluded in your plan. Our office DOES NOT determine which category your insurance will process your payments prior to billing. This is something you can do by calling your insurance company and asking them to run a "TEST CLAIM" (details below).
2. Physical Health vs Mental Health: Depending on the diagnosis code that was used by your doctor and/or therapist when your child was referred for therapy services, your benefits may be processed under physical health benefits or mental health benefits. Our office has no control over which category will be used by your insurance company. Many plans have very different costs associated with physical health vs mental health benefits and you will be responsible for your portion of the costs. It is important to note that two different therapists (for example physical therapy vs speech therapy) may process in two different categories for the same child. The only way you can determine how these will process is for you to call your insurance company and run a "TEST CLAIM" (details below). Our office DOES NOT run test claims prior to treatment.
Test Claims:
We highly recommend you run a test claim to better understand what you will owe for therapy services based on your insurance company's benefits. Here are the steps to running a test claim:
1. Call our office and request the codes being used for your child's therapy so you can run a test claim.
** You will need to provide the ICD-10 code that our clinic is using to bill your services. This is the diagnosis code. Your child may have more than one code. Our office will provide you the codes and tell you the order they should be listed.
**You will need to provide the CPT codes that our clinic is using in therapy. These are the "procedures" being used in therapy. Our office will provide you with all the potential CPT codes that may be used in therapy.
2. Call the member number on your insurance card
3. Ask to run a TEST CLAIM for therapy services for your child. You will provide the codes you have received from our office. You want to find out:
* Limits to your therapy services
*Your associated costs (i.e. deductible, co-insurance, exclusions to services, etc). Remember, different services will be processed in different ways by your insurance and you may have very different expenses based on how the visits are processed.
Coordination of Benefits:
If your child is covered by more than one insurance you will need to determine which insurance is the primary insurance and which insurance is the secondary insurance. This is not something you get to pick. It is often associated the with the subscriber's birthdate. To coordinate your benefits effectively and not have any surprise bills you should do the following:
1. Make sure our office has accurate insurance information for ALL plans. If you do not provide the information to us we cannot bill your insurance. If mis-information or lack of information provided by you results in our office being unable to be reimbursed for services provided to you, these costs will be passed on to you.
2. Call your insurance companies to find out which insurance is your primary and your secondary insurance.
3. When your insurance company contacts you to update your information you must do so or your claims will be denied.
4. If your insurance company denies a claim under "Coordination of Benefits" as the reason, you as the member must call and correct this information with your insurance company or the financial responsibility of the visit will fall to you.
Deductibles, Co-Insurance, Co-Pays:
Deductible: This is the amount you have to pay before your insurance benefits pay their portion. If you have a $1000 deductible, you will have to pay this amount before your co-insurance kicks in.
Co-Insurance: This amount is typically a percentage of the amount that is billed to your insurance. For example, if your co-insurance is 20% this means that if you have a $100 bill your insurance will pay $80 and you will be required to pay $20. Typically you have to meet your deductible first and then your co-insurance benefit will start.
Co-Pays: This ia a flat amount that you are required to pay for a visit and your insurance pays the rest of the cost. For example, if you have a co-pay of $30 per visit, that is what you will owe for every visit completed. Usually, but not always, your deductible does not have to be met prior to paying co-pays.
Understanding My Bill and Making Payments:
We strive to make our billing and payment systems easy to use and transparent. Please call or email our office with further billing questions.
Understanding Your Invoices:
Our office sends a separate invoice for each month that claims are processed and charges are incurred. You will not receive an invoice if your insurance company has not yet processed your claims. If you receive more than one invoice it means you have more than one balance due.
Balances should be paid upon receipt. If you cannot pay your full balances please call our office to set up a payment plan. It is important that you set up a payment plan with our office to ensure that you can stay caught up with your incurred costs. Invoices that are 90 days past due from the original date of the invoice will be sent to collections even if you have made partial payments. If you have not set up an official payment plan with our office, the balance will be sent to collections. Therapy services will be suspended at that time. **We do not make individual phone calls to inform you that you have a past due balance**.
Making Payments:
You can pay your bill in a variety of ways.
1. Online patient portal: https://app.fusionwebclinic.com/portal/prismpediatrics. There is a 3% processing fee for all card payments (except HSA cards). You received a link to enroll when you started therapy services. If your link has expired you can call our office to receive a new invitation link.
2. Call our billing office: 360-800-6401. There is a 3% processing fee for all card payments (except HSA cards).
3. Mail a personal check.
4. Set up payment through your bank's online bill pay.
5. Pay in person via card (3% fee except HSA cards), check, or cash.
