Even if a provider is listed as in-network, coverage can vary widely by plan. Verifying your insurance coverage helps ensure you understand what services are included, what your out-of-pocket costs may be, and prevents billing surprises. Here’s why it matters:

• In-Network ≠ Covered: Some services require pre-authorization or aren’t included in your specific plan.

• Billing Errors Happen: Mistakes do occur, and verification helps catch them early.

• Network Tiers Can Impact Cost: Different tiers within a network can mean different co-pays or deductibles.

• Out-of-Network = Higher Cost: Without verification, you could unknowingly receive care that isn’t covered.

• Peace of Mind: Knowing your benefits helps you focus on care—not confusion.

Here’s how to confidently confirm your benefits with your insurance provider:

1. Prepare Your Info:
   Have your insurance card, our practice name (Synapse Solutions), provider name, and address handy:
   111 N Main Street, Suite 100, Janesville, WI 53545
   
   

2. Call the Number on Your Card:
   Dial the customer service number on the back of your insurance card.
   
   

3. Provide Personal Details:
   Share your full name, policy/member ID, and date of birth.
   
   

4. Ask About Coverage:
   Specify the type of service you're seeking:

• Outpatient Therapy Services

• Psychological or Neuropsychological Testing
  
  

5. Reference CPT Codes:
   These are common codes your insurance may ask for:

• Therapy: 90791 (Intake), 90834 or 90837 (Therapy Sessions)

• Testing: 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96116, 96121
  
  

6. Confirm Network Status:
   Verify that both the provider and facility (Synapse Solutions) are in-network.
   
   

7. Ask About Costs:
   What is my copay, deductible, or coinsurance?
   What percentage of the service is covered?
   
   

8. Ask About Session Limits:
   Are there any limits on the number of visits allowed per year?
   
   

9. Document Everything:
   Record the date of your call, who you spoke with, and the information provided.
   
   

Understanding the difference between a guarantor and patient responsibility can help clarify medical billing and ensure transparency throughout your care.

What Is a Guarantor?

• The guarantor is the person legally responsible for paying a patient's medical bills.

• This is often the patient themselves, but may also be a parent, spouse, legal guardian, or another person who agrees to take on financial responsibility.

• The guarantor is responsible for the full balance, even if the patient’s insurance does not cover the total cost.

• This includes copayments, deductibles, coinsurance, and any other out-of-pocket costs.

What Is Patient Responsibility?

• Patient responsibility refers to the portion of healthcare costs a patient is expected to pay.

• This includes copays, deductibles, coinsurance, and services not covered by insurance.

• These amounts vary based on your insurance plan and the services you receive.

• For example: A patient may owe a $20 copay for a visit, a $500 yearly deductible, and 20% coinsurance on tests or procedures.

Key Differences: Guarantor vs. Patient Responsibility

• The guarantor is legally responsible for the entire bill.

• The patient is responsible for their specific portion of the cost.

• The guarantor may or may not be the patient, especially in cases involving minors or dependents.

• The patient is the one receiving care, but the guarantor is the one ultimately billed.

Examples

• A parent is the guarantor for their child’s services.

• A spouse may be the guarantor for their partner’s care.

• A legal guardian may be responsible for their ward’s bills.

• An uninsured adult patient is their own guarantor.

• A patient with insurance is still responsible for their copayments, deductibles, and coinsurance.

Special Notes About Medicaid Billing

Medicaid is a government-funded program for eligible individuals and families with low income. When a patient is covered by Medicaid:

• The government pays the provider directly.

• Patients are not responsible for the remaining balance of covered services.

• Providers cannot “balance bill” the patient for any unpaid portion.

However, Medicaid patients may still be responsible for:

• Copays or deductibles (if applicable in your state).

• Non-covered services (services not included in Medicaid coverage).

• Services received while ineligible or not enrolled in Medicaid.

Tips for Medicaid Patients

• Make sure your eligibility is current and you are enrolled.

• Provide your Medicaid ID at every appointment.

• Confirm that your provider accepts Medicaid before receiving care.

• Review your Explanation of Benefits (EOB) for accuracy.

• Contact your local Medicaid agency if you receive a bill or have questions.

Medicaid is a government-funded insurance plan for eligible individuals and families with low income. 

Here's what you should know:

• Medicaid pays providers directly.

• Patients cannot be balance billed for covered services.

• Providers must accept the Medicaid-approved rate.

However, patients may still be responsible for:

• Copays or deductibles (if applicable)

• Services not covered by Medicaid

• Services received while not eligible or not enrolled

Tips for Medicaid Patients:

• Ensure your enrollment is current.

• Provide your Medicaid ID at every visit.

• Ask if the provider accepts Medicaid before your appointment.

• Review your Explanation of Benefits (EOB) regularly.

• Call your Medicaid agency with any questions or unexpected bills.