Billing and Financial Information

Medical Billing Terms

Copayment: A fixed payment the patient pays each time they visit a health plan clinician or receives a covered service.

Deductible: More typical in traditional health insurance, a fixed amount the patient must pay each year before the insurer will begin covering the cost of care.

Fee-for-service: The traditional method of paying for medical services. A provider charges a fee for each service given, and the insurer pays all or part of that fee. Sometimes the patient pays a copayment for each visit to the provider.

Health Maintenance Organization (HMO): An organization that offers healthcare services in exchange for fixed monthly payments. Most HMOs provide care through a network of hospitals, doctors and other medical professionals, which members must utilize to receive coverage for their care.

Managed Care Organization: An umbrella term for HMOs and all health plans that provide health care in return for set monthly payments and coordinate care through a defined network of primary care providers and hospitals.

Network: The doctors, clinics, health centers, medical group practices, hospitals, and other providers that an HMO, PPO, or other managed care plan has selected and contracted with to care for its members.

Out-of-network: Not in the HMO’s network of selected and approved providers and hospitals. HMO members who get care out-of-network (sometimes called out-of-area) without getting permission from the HMO to do so may have to pay for all or most of that care themselves. Exceptions are usually made for extreme emergencies or urgent care needed when traveling from home.

Point-of-Service (POS) Plan: A type of HMO coverage that allows members to choose to receive services either from participating HMO providers, or from providers outside the HMO’s network. In-network care is more likely to be fully covered; for out-of-network care, members pay deductibles and a percentage of the cost of care, much like traditional health insurance coverage.

Practice Guidelines: Carefully developed information on diagnosing and treating specific medical conditions. Practice guidelines, usually based on clinical literature and expert consensus, are designed to help providers and patients make decisions, and to help a health plan evaluate appropriateness and medical necessity of care.

Preferred Provider Organization (PPO): A network of providers and hospitals that provides care at a lower cost than through traditional insurance. PPO members get better benefits (more coverage) when they use the PPO’s network and pay higher out-of-pocket costs when they receive care outside the PPO network.

Preventive Care: Care designed to prevent disease altogether, to detect and treat it early, or to manage its course most effectively. Examples of preventive care include immunizations and regular screenings like Pap smears or cholesterol checks.

Primary Care: Preventive health care and routine medical care that is typically provided by a provider trained in internal medicine, pediatrics or family practice.

Primary Care Provider (PCP): A provider, usually an internist, pediatrician or family provider, devoted to the general medical care of patients. Most HMOs require members to choose a primary care provider, who is then expected to provide or authorize all care for that patient.

Referral: A formal process that authorizes an HMO member to get care from a specialist or hospital. To assure coverage, an HMO patient generally must get a referral from their primary care provider before seeing a specialist.

Specialist: A health professional whose training and expertise are in a specific area of medicine, like cardiology or dermatology. Most HMOs require members to get a referral from their primary care provider before seeing a specialist.

What Should I Know Before Choosing a Health Plan?

Coverage: What services does the plan cover? What are the deductibles? Does it cover home care, chiropractic services, mental health services, or anything else that is particularly important to you?

Choice: Is there a certain doctor you’d like to choose, either for routine care or specialty care? Do you have to choose a provider from among those specified? Do you have a primary care hospital? If you have different rules for “emergency care” and “urgent care” how do you define the difference between the two?

Convenience: Does your plan cover providers who are located near your home or office? What is the procedure if you choose a provider and then find that you do not like him/her?

Cost: You will pay all or part of the premium directly or through payroll deduction, plus a visit fee, or co-payment, whenever you get care. If your coverage is through your employer, your benefits manager can tell you what your portion of the premium will be. If you are in a Medicare managed care plan, there may be no premium.

Other

• Are the deductibles one time only, or yearly?
• Is the insurance provider financially stable?
• Is the plan accredited by NCQA? The National Committee for Quality Assurance is a non-profit watchdog organization created to assess, measure and report on care provided by the nation’s managed care groups. Since 1991, NCQA accreditation surveyors–mainly doctors–have evaluated a health plan’s organization, structure and quality improvement processes to see whether the plan was capable of delivering high quality care and continually improving the care it provided?
• How long has the company been in business?
• What is the average turn-around time on claims?

Put It All Together: Is the combination of cost, quality, coverage and access to your preferred providers or specialists acceptable?

Insurance Participation

Central Maine Healthcare (Bridgton Hospital, Central Maine Medical Center and Rumford Hospital) accepts most major insurance companies.  Below is a list of insurance companies that we participate with. If you don’t see your specific plan or product below, please contact your insurance company customer service department to check that the facility you will be receiving care at is a participating provider.  Each patient’s medical situation and insurance plan are different and you should ask your health insurance company to review your coverage and benefits at Central Maine Healthcare’s facilities. Insurance plans are agreements made between you and your insurer, and Central Maine Healthcare cannot ensure that an insurance company will pay for your care. It is your responsibility to understand what types of coverage your health insurance provides and to be sure that you meet all requirements stipulated by your specific plan. Your health insurance company will be able to inform you of your level of coverage and what, if any, copayments, coinsurances and deductibles will be your responsibility.  Many insurance plans are now considered “tiered” plans, and have different levels of costs depending on where you go for care. It is important that you check with your own health insurance plan to see what level of coverage you will receive at a specific hospital. Even if you see your insurance plan listed, additional referrals or authorizations may be required. Some services may not be covered by your insurance coverage at every location.  The level of coverage provided to you is determined by your insurance company.  Also, many health insurance plans use other companies to cover certain services such as behavioral health (mental health).  Please contact your insurance plan or employer for your specific questions.

CMH Contracted Insurance Plans

• Aetna
• Aetna Medicare Advantage
• Anthem
• Anthem Medicare Advantage
• CHAMPVA
• Cigna
• Community Health Options
• Harvard Pilgrim
• Humana Medicare Advantage
• MaineCare
• Martin’s Point Generations Advantage
• Martin’s Point USFHP
• Medicare
• Meritain Health
• Multiplan
• NH Medicaid
• Patient Advocates
• TRICARE
• UnitedHealthcare
• UnitedHealthcare Medicare Advantage
• VA Community Care Network (VACCN)
• Wellcare Medicare Advantage

FAQ

Answers to Your Billing Questions

What is a deductible? Coinsurance? Co-payment? Insurance plans generally have deductibles, co-payments, and/or coinsurances that are the responsibility of the subscriber, patient, and/or guarantor.

Deductible: A “deductible” is an annual expense that you must pay before your insurance benefit can begin. This amount can vary based on a place of service (i.e. provider’s office vs. hospital). Supplemental insurance plans may cover this cost; however, it is based on your selected insurance benefit package.

Coinsurance: A “Coinsurance” is the percentage of the total bill that is the patient and/or guarantor’s responsibility to pay. This amount can vary based on place of service (i.e. provider’s office vs. hospital). Supplemental insurance plans may cover this cost; however, it is based on your selected insurance benefit package.

Co-payment: A “Co-payment” is a set amount paid at each visit, based on your selected insurance benefit package. This is usually not applied towards your deductible.

For example: On a $1000 bill, your deductible might be $200, so you would have to pay the first $200. This leaves a balance of $800. Of that $800, your co-insurance might be 20%, meaning that you will be responsible to pay $160. Your insurance company should pay $640. Once the insurance company has made payment, you should receive an explanation of benefits from your insurance and will receive a statement from the hospital indicating the remaining balance.

Questions related to an insurance company payment and/or denial should be made directly to your insurance company or benefits office.

Who is responsible for paying my bill? The hospital will bill your insurance directly, unless specified otherwise. You are ultimately responsible to make certain that your bill is paid, either by the insurance and/or responsible party. If a balance remains after your insurance has issued a payment or a denial, payment is due immediately upon receipt of your statement from the hospital.

How can I pay my bill? There are several payment options:

• Secure online bill payment at Pay Your Bill Online
• To pay with credit or debit by telephone contact us at:
  • Lewiston Area: 1-833-486-2738
  • Bridgton Area: 1-833-486-2738
  • Rumford Area:  In state toll-free number 1-833-486-2738
• We accept Visa, MasterCard, Discover and American Express
• Cashier’s check, personal check or credit card information can be mailed to the following address. Indicate account number on the lower left-hand corner of the check:
  • Central Maine Healthcare
    PO Box 4100
    Lewiston, Maine 04243-4100
• Visit the following locations to make a payment in person:
  • CMH Patient Financial Services
    29 Lowell Street, 1^st Level
    Lewiston, Maine 04240
  • Bridgton Hospital
    10 Hospital Drive
    Bridgton, Me 04009
  • Rumford Hospital
    420 Franklin Street
    Rumford, Maine 04276

What other bills will I receive? In addition to your bill from the hospital or its providers, you may receive bills from private providers who took care of you. These providers who may or may not participate in your health care may include:

• Primary Care provider
• Surgeon
• Anesthesiologist
• Radiologist
• Pathologist
• Other specialist

Did you bill my correct insurance? Insurance-related questions may be directed to the Patient Financial Services department by calling 1-833-486-2738 or one of the telephone numbers listed above.

What is “pending” with my insurance? You may have received a letter or questionnaire from your insurance company requesting additional information. If you do not respond to this request, the bill may ultimately become your responsibility. Questions about your account may be directed to the Patient Financial Services department at 1-833-486-2738 or one of the telephone numbers listed above.

What do I owe? You should receive an account statement in the mail. Your statement will reflect any unpaid balances on your accounts. Questions related to account statement balance can be directed to the Patient Financial Services department at 1-833-486-2738 or one of the numbers listed above.

Did you receive my payment? There may be times where a statement is generated prior to your payment being posted. Any new payments on your account should be reflected on your next account statement. Questions about your account may be directed to the Patient Financial Services department by calling 1-833-486-2738.

What if I didn’t have my insurance information at the time of service? You should contact the Patient Financial Services department immediately by calling 1-833-486-2738 or one of the telephone numbers listed above to ensure proper billing requirements are met, and to prevent pre-certification and timely filing issues with your insurance plan.

What are a referral and a pre-certification, and who is responsible for taking care of these?

Referral: Many insurance plans require a referral from your Primary Care provider to a specialist and/or the hospital for specific services. Without a referral from your Primary Care provider, services are often denied for payment and the bill may ultimately be your responsibility.

Pre-certification: Many insurance plans require prior approval for services by patients, their Primary Care provider, or ordering provider before services can be covered. Without pre-certification from the ordering provider, services are often denied for payment and the bill may ultimately be your responsibility.

Please review your health plan booklet or call your insurance company to clarify your benefits, referral, and pre-certification requirements prior to receiving any services.

Why didn’t my insurance pay? You should have received an Explanation of Medical Benefits (EOMB) or Explanation of Payment (EOP) from your insurance company, showing how they considered your claim. This EOMB/EOP should have a contact telephone number or website where you can reach your insurance company for questions. Please contact your insurance company or benefits office with questions about denied claims.

I was injured at work – why am I getting a bill? After notifying your employer of a work-related injury, your employer should have filed a ‘Notice of Injury’ with the company’s worker’s compensation carrier. If they did not, the claim may be denied and become your responsibility.

Facility Charges/Fees

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