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Insurance as a Contract Between You and Your Provider

Your health insurance policy is a contract between you and your insurance company, not between the insurance company and our office. Coverage decisions, visit limits, copayments, deductibles, and medical necessity determinations are made solely by your insurer.

 

As a courtesy, our office will:

 

• Verify benefits when possible

• Submit claims on your behalf

• Provide documentation to help you understand your Explanation of Benefits (EOB)

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However, verification of benefits is not a guarantee of payment.

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In-Network Insurance Plans

 

We are in-network with many major PPO plans, including:

• Aetna PPO (non-Medicare plans)

• Blue Cross Blue Shield PPO

• Blue Cross Blue Shield Blue Choice PPO

• Blue Cross Blue Shield Federal

• Empire Blue Cross Blue Shield

• UnitedHealthcare PPO (non-Medicare plans)

• UMR and Golden Rule

Coverage and reimbursement vary significantly by plan, even within the same insurance company.

 

Out-of-Network, Medicare & Medicaid

• Cigna: May be billed out-of-network if your plan allows

• Medicare & Medicare Supplements: All providers are non-participating and we cannot bill Medicare or Medicare supplemental plans

• Medicaid: Not accepted

 

As of December 1, 2024, all providers at River Forest Health & Wellness are non-participating with Medicare and Medicare supplement plans.

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Patient Financial Responsibility

Patients are financially responsible for all services rendered, regardless of insurance coverage or claim outcomes.

 

This includes, but is not limited to:

• Deductibles

• Copayments

• Coinsurance

• Non-covered services

• Denied or partially paid claims

• Services exceeding visit limits or frequency caps

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Payment for copays and known balances is expected at the time of service.

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Claims Processing & Timelines

• Insurance claims are typically processed within 15–45 days, though timelines vary by carrier

• Insurance payments are sent directly to our office when we are in-network

• Once insurance has processed the claim, a statement will be sent for any remaining patient balance

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Please note: Insurance companies do not always pay based on our billed charges, and reimbursement amounts are determined by your insurer.

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Explanation of Benefits (EOB)

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After a claim is processed, your insurance company will send you an Explanation of Benefits (EOB). This is not a bill, but rather a summary of:

 

• What was billed

• What the insurance paid

• What portion (if any) is your responsibility

 

We strongly encourage patients to review their EOB carefully and contact their insurance company directly with questions regarding coverage decisions.

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Denied or Reduced Claims

Claims may be denied or reduced for reasons including, but not limited to:

 

• Lack of medical necessity as defined by the insurer

• Visit limits reached

• Diagnosis-specific exclusions

• Missing referrals or authorizations (when required)

• Policy-specific exclusions

 

 

If a claim is denied, the balance will become the patient’s responsibility. We are happy to provide documentation if you wish to appeal directly with your insurance company.

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Pre-Authorization & Referrals

Some insurance plans require:

• Prior authorization

• Referrals from a primary care provider

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It is the patient’s responsibility to ensure these requirements are met. Failure to obtain required authorizations or referrals may result in denied claims and full patient responsibility.

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Non-Covered & Private Pay Services

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• Massage therapy is not billed to insurance and is private pay

• Certain services, modalities, or extended visits may not be covered by insurance

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If a service is expected to be non-covered, we will do our best to inform you in advance.