Out-of-Network Insurance at Manhattan Pain Medicine

“Out-of-network” means we do not have a direct contract with your insurance company. While this may result in higher out-of-pocket costs for some patients, it also allows us to offer personalized, comprehensive care without the limitations of in-network restrictions. And in many cases, the difference in cost is lower than patients expect. 

We will bill your insurance for you. All costs are shared upfront and made available on our website. You’ll be informed of your estimated cost-share based on anticipated insurance reimbursement. Since the exact amount covered by insurance isn’t known until the claim is processed, we collect a deposit at the time of your visit and reconcile it once the claim is finalized. Your initial deposit will go toward your final cost of treatment, however, if the entire balance is not covered you may be responsible for the difference. 

Please see our self-pay fee schedule for reference regarding out-of-pocket costs without insurance.

Our Process

  1. Insurance Verification: We will call your insurance and verify your benefits.
  2. Benefits Explanation: Someone from our office will describe your benefits and what any out-of-pocket costs may be with our office
  3. Cost Share and Deposit: Your cost share is estimated up front and will be collected as a deposit at the time of visit.
  4. Insurance Payment: When your insurance pays, we balance the books. As insurance is unpredictable, you may have a balance OR be due a refund.  
  5. Insurance Billing: We bill the insurance for you, just as in-network.
  6. Receiving Checks for Out-of-Network Services: If your insurance company sends a check to you for services we’ve billed, please deposit it and pay Manhattan Pain Medicine the same amount within 15 days. Include the Explanation of Benefits (EOB) so we can apply the payment correctly. If the insurer’s payment doesn’t cover the full charge, you’re responsible for the remaining balance.
  7. Savings Programs: We have a team to help submit claims to any savings programs you may be eligible for to minimize out-of-pocket costs and reimburse you for any upfront expenditures. While savings programs are not guaranteed refund or reimbursement tools, they’re an option we help explore.

Alternatives

  1. Superbill Generation to pay up front: If you prefer to pay up front, we provide you with a detailed “superbill”. This document includes all the necessary information to submit a claim to your insurance company for reimbursement.
  2. Self-Pay Options: We accept self-pay for those without insurance or with limited out-of-network benefits. We strive to provide transparent pricing and work with you to manage costs effectively.
  3. Good Faith Estimate for Self-pay: If you are uninsured or choosing to self-pay, you are entitled to receive a Good Faith Estimate of the expected charges for your care. This must be provided at least 3 business days before your scheduled appointment or procedure. You can find your Good Faith Estimate form HERE

Frequently Asked Questions:

Yes. Please bring your current insurance card and a valid photo ID to every single appointment, not just your first visit. This helps us verify your coverage accurately and avoid delays or billing issues. Outdated or missing documents can affect claim processing.

  • Deductible: The amount you pay out-of-pocket before your insurance starts to contribute.
  • Coinsurance: A percentage of costs you share with your insurance after your deductible is met.
  • Cost share: The total amount you pay for out-of-network care, typically deductible, coinsurance, and any copays. Unlike a copay (a fixed per-visit fee), cost share reflects your overall costs across services and may include balance billing if your insurance does not cover the full fee.

Once we receive your insurance information, we contact your provider to verify your out-of-network benefits. We then explain your coverage, including any expected deductible, coinsurance, or other cost-share responsibilities.

We provide an estimated cost share before your visit. This amount is collected as a deposit at the time of service. Once your insurance processes the claim, we reconcile the deposit:

  • If your insurance pays more than estimated, we issue a refund.
  • If your insurance pays less, you may receive a balance due.

Note: Depending on your plan’s rules and how your insurer processes out-of-network claims, you may owe more than our published fee schedule.

If you are uninsured or choosing to self-pay, you are entitled to receive a Good Faith Estimate of the expected charges for your care. This must be provided at least 3 business days before your scheduled appointment or procedure. You can find your Good Faith Estimate form HERE

Some plans send reimbursement directly to you. If you receive a check, please deposit it and pay Manhattan Pain Medicine the same amount within 15 days. Include your Explanation of Benefits (EOB) so we can apply the payment correctly. If the insurer’s payment is less than our fee, you’re responsible for the remaining balance.

We offer a Superbill upon request. This detailed invoice includes everything you need to submit a reimbursement claim. We also assist with Savings Programs, if applicable; however, participation is not guaranteed, and reimbursement is not automatic.

Patients may request an Economic Hardship Application, which is reviewed case-by-case. While it does not guarantee a discount, we will do our best to work with you if you’re experiencing financial challenges.

Many services — including labs, biopsies, and imaging — require prior authorization from your insurance. These approvals may require proof that you’ve completed prior steps, such as 6 weeks of physical therapy. We need to gather this documentation early so we can prevent delays.

Botox treatments follow a specific schedule and require insurance approval. Your upfront amount due is based on the number of units administered plus an administration fee and will serve as a deposit toward the final treatment cost. If insurance does not cover the full balance, you may be responsible for the difference. We offer a Savings Program to assist with the final cost.

  • Personalized Care: Our highly personalized approach ensures that each patient receives the care they need, rather than what an insurance company might deem adequate.
  • Collaborative Treatment Plans: We work closely with you and your other healthcare providers to create a comprehensive and effective treatment plan.
  • Holistic Approach: We incorporate various treatment modalities, including medications, physical therapy, targeted injections, and pain psychology, to address all aspects of your pain.

*Exceptions: Anthem BCBS Illinois and Federal employee programs. Anthem pays patients directly, so you will receive a check for services rendered by our office. If there is a pending balance on the account it means your initial cost share payment and insurance together covered a portion of the total and you would owe the balance.

We’re happy to go over any part of this with you if you have questions.

If you have any questions about your insurance coverage or need assistance with payment, please don’t hesitate to contact us. Our friendly staff is here to help you navigate the process and ensure you receive the best possible care..