How can I tell what insurance my pediatrician accepts?
Two calls can help clear things up: one to the practice, one to your insurance company.
An online list does not guarantee your child’s coverage. Check the exact plan, clinician, office and visit type with both the practice and your insurer.
Start with your child’s card.
Find the insurer, full plan name, network name, member number and member-services phone number. A carrier can offer many different networks. “We accept Aetna” does not establish that your particular Aetna plan is in-network.
Check the insurer’s directory.
Use the member portal shown on your card so you search within your actual plan. Look up the clinician’s name and the exact office address. If you cannot find a match, call member services.
Call the practice.
Ask about your exact plan, the clinician your child would see, new-patient availability and any referral requirements. Ask for the clinician’s NPI if your insurer needs it to identify the right person.
Confirm with your insurer.
Ask whether that clinician at that address is in-network under your child’s current plan. Ask about expected cost sharing and any approvals needed for the planned visit. Record the date, representative’s name and reference number.
“Hi! I’m choosing a pediatrician for my child…”
“Our exact insurance plan is [plan and network]. Is [clinician] at [office address] in-network for that plan? Are you accepting new patients? Is there anything we need to arrange before our first visit?”
A few things to keep separate
Accepted insurance versus in-network care
An office may be willing to bill an insurer without being in your specific network. Ask both sides about your exact plan rather than relying on the carrier name alone.
Medicaid and Florida KidCare
Use the actual plan named on your child’s enrollment materials. Do not assume a general Medicaid or Healthy Kids listing applies to every participating plan. Ask the practice and plan about that specific enrollment.
Membership practices
Direct-care memberships may charge separate fees and may not bill insurance. Ask what the membership covers and what it does not. A membership is not a substitute for checking insurance coverage for outside services.
Further reading: HealthCare.gov: getting medical care. Directory guidance, not insurance or medical advice.
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