Insurance & Out-of-Network Reimbursement
At Eastside Menopause & Metabolism, we practice Direct Specialty Care. This allows us to spend more time with our patients, provide highly personalized care, and make medical decisions based on your needs rather than insurance requirements.
Because of this model, we do not bill or contract with any insurance companies.
How Payment Works
Payment is due at the time of your visit.
After your appointment, you will receive:
An itemized invoice for your visit
A superbill that includes the diagnosis and procedure codes your insurance company may require
If you have commercial insurance, you may choose to submit these documents directly to your insurance company to request out-of-network reimbursement.
Please note that reimbursement is determined entirely by your insurance plan. Eastside Menopause & Metabolism cannot guarantee that your insurance company will reimburse any portion of your visit.
How to Check Your Out-of-Network Benefits
Before scheduling an appointment, we encourage you to contact your insurance company to learn about your out-of-network benefits.
You can usually find the Member Services phone number on the back of your insurance card.
Questions to Ask Your Insurance Company
You may find it helpful to ask the following questions:
Does my plan include out-of-network benefits for physician office visits?
What is my out-of-network deductible, and has it been met?
What percentage of an out-of-network office visit will be reimbursed after my deductible?
Is prior authorization or a referral required for out-of-network specialty care?
Is there a limit on the number of out-of-network specialist visits covered each year?
Do I need to submit a claim myself, or can I submit a superbill provided by my physician?
Where should I submit my claim, and what forms are required?
How long does reimbursement typically take?
What We Provide
To help you request reimbursement, we are happy to provide:
An itemized invoice
A superbill with the appropriate CPT and ICD-10 codes
Documentation of services provided, if requested by your insurance company
What We Do Not Do
As a Direct Specialty Care practice, we do not:
Bill insurance companies
Submit claims on your behalf
Appeal denied insurance claims
Communicate directly with insurance companies regarding reimbursement
Verify or estimate your insurance benefits
Your insurance company is the best source of information regarding your specific coverage and reimbursement eligibility.
HSA & FSA
Many patients use Health Savings Accounts (HSAs) or Flexible Spending Accounts (FSAs) to pay for visits. We recommend confirming eligibility with your HSA or FSA administrator if you have questions about your plan.
Medicare, Medicaid & TRICARE
Due to federal regulations, Eastside Menopause & Metabolism is unable to provide care to patients enrolled in Medicare, Medicaid, or TRICARE.
Frequently Asked Questions
Does being out of network mean my insurance won't pay anything?
Not necessarily. Many commercial insurance plans include out-of-network benefits. If your plan offers these benefits, your insurance company may reimburse you for a portion of your visit after you submit your superbill. The amount reimbursed varies by plan.
Can you tell me how much my insurance will reimburse?
Unfortunately, no. Every insurance plan is different, and reimbursement depends on your individual policy, deductible, and out-of-network benefits. Your insurance company is the only source that can provide this information.
Will you submit my claim for me?
No. As a Direct Specialty Care practice, we do not submit insurance claims. We will provide you with an itemized invoice and superbill that you may submit directly to your insurance company if you choose.
What if my insurance doesn't reimburse me?
You are responsible for the full cost of your visit regardless of whether your insurance company provides reimbursement. We encourage all patients to verify their out-of-network benefits before scheduling an appointment if reimbursement is important to them.