The Billing Process
Apollo Laboratory performs specialized urine drug toxicology and molecular testing for infectious diseases. Once performed the results are reported in an easy to read format to the ordering provider. At that time, Apollo will submit the claim to the patient’s respective insurance carrier (Payer).
The factors that affect a payer’s decision to reimburse these specialized tests include the patient’s diagnosis, the payer’s policy or specific coverage determination to reimburse such tests.
2. Communications with Patient
2.1 Explanation of Benefits (EOB) statement
Once the claim has been received by the payer, the claim is processed and an Explanation of Benefits (EOB) statement is sent to the patient showing the services provided by Apollo. It should be noted that
- 2.1.1 The EOB is not a bill.
- 2.1.2 The EOB is a statement explaining the charges paid by the payer for the testing services provided by Apollo.
- 2.1.3 The EOB will indicate all services covered by patient’s insurance policy on the claim.
- 2.1.4 Patient out-of-pocket liability will be based on the policy coverage and the status of their deductible and co-insurance.
2.2 Error Processing (EP) Letters:
Patients and the ordering physician will receive EP letters from Apollo requesting missing demographics information related to insurance policy such as identification number, date of birth, full name of policy holder, ordering physician information, medical necessity, etc.
2.3 Medical Necessity Letters
The definition of “Medical Necessity” by Medicare and various insurers states that the items or services be “reasonable and necessary” for the diagnosis or treatment of illness to be eligible for payment. Not only Medicare but other payers request such information. Unless the requested information is provided the claims will not be processed expediently and will be delayed.
3.1 Insurance Denies Reimbursement for Testing:
If a payer denies paying the claim, or pays only a portion, Apollo will submit an appeal on patient’s behalf to the payer. Apollo is committed to completing up to three levels of appeals, including independent medical review if available in patient’s state. Apollo may ask the patient and the physician to assist in the process as needed. Depending on the payer, this can be a very lengthy process. Apollo will keep the patient notified as needed during this process.
3.2 Insured Patients are Billed Outstanding Balance, Deductibles and Co-Insurance as Required by Their Payer:
Payers require Apollo to bill patients for any applicable deductible, outstanding balance, and co-insurance, as reflected on EOBs or similar statements furnished by the payer. The amounts are determined by the patient’s insurers, not by Apollo. Patients will receive a patient statement from Apollo, which will indicate the balance due for the testing services provided.
Payers require Apollo to register with them at first and then process applications to get credentialed. When credentialed, a contracted reimbursement rate is generally established with the payer.
Apollo bills patient for the amount designated by their plan as the patient’s responsibility, including and balances remaining on the bill if the payer pays less than the “usual and customary,” “reasonable” or “allowable” charge (collectively termed the “Allowable Charge”) for the service provided. The payer will determine the Allowable Charge on the EOB. If the full Allowable Charge is paid to Apollo by the payer, patient will not be billed by Apollo.
4. Insurance Payments Paid Directly to Patient
Some payers have a policy to send reimbursements directly to the patient for the testing services rather than to Apollo. If a patient receives such a payment from their insurance company for our testing, it is the patient’s responsibility to pay Apollo Laboratory within ten days of receipt of that payment.
5. Patient Self-paying for the Test
If the patient’s insurance plan deems this testing as research or investigational and the patient believes the clinical benefits outweigh the financial cost, the patient can pay out of pocket for testing.
6. Refund of Over-payments:
If Apollo Laboratory determines that an over-payment that been made the credit balance will be submitted for refund to the proper party, regardless of whether a refund has been requested.
7. Apollo Laboratory Contact Information
3191 Beaumont Centre Circle
Lexington, Kentucky 40513
Phone number (859)-320-0412
FAX number is (888)-977-1886