DO YOU HAVE SOME QUESTIONS THAT NEED ANSWERS?

DO YOU HAVE SOME QUESTIONS THAT NEED ANSWERS?

FREQUENTLY ASKED QUESTIONS

When do you start an out-of-network request?

All out-of-network requests should be started within 30 days of your appointment. This is a slow process as all requests are done one-by-one by phone.

All new patient requests should be started within 30 days of their initial visit appointment.

All other patients will need to make a blood draw appointment and start their request within 30 days of their appointment.

What documents are needed for an out-of-network request?

Please ensure that the Food Allergy Institute has a copy of your insurance card; front and back.

 

What are the outcomes for an out-of-network request?
  • Out-of-network request outcomes for both initial visits and blood draw:
    • Approved in-network: The insurance will cover the blood draw at an in-network rate. The patient will pay the same amount as if you went to another national lab.
    • Approved out-of-network: The insurance will cover the blood draw using your out-of-network plan. This is usually at a higher rate for the patient. 
    • Approval partial: The insurance will cover some of the bill.  E.g. If the insurance will only cover $2000. The patient will be balance billed $500 to equal $2500.
      • All codes that are denied will be appealed 1 time. 
    • Denial: Insurance will not cover any of the bill.
      • What happens now?
        • Patient’s can get drawn and we will appeal on the backend.
          • Appeal outcome:
            • Approved/covered: Insurance will cover the lab work.
            • Partial approval: The insurance will cover some of the bill. If the insurance will only cover $3000, the patient will be balance billed $500 to equal $2500.
            • Denied: The patient is responsible for the total lab cost $2500. ***Note: Patient will never pay more than $2500.***
              • Option for payment
                • Pay in full 
                • Options for payment:
                  • A four-month or six-month payment plan directly with TPIRC Diagnostic
                  • Affirm: Multiple payment plan options including six months of interest-free payments https://m.affirm.com/tpirc
                  • Caredcredit: Interest-free plans of 6 or 12 months www.carecredit.com
Who needs an out-of-network request?

All patients that need blood work to accept cash patients/ Kaiser patients/and certain insurance that do not allow for out-of-network requests/GAP/ PPO waiver.

 

What are the different types of insurance that patients may have?
  • PPO/Commercial
    • PPO plans include out-of-network benefits. They help pay for care you get from providers who don’t take your plan. But you usually pay more of the cost. For example, your plan may pay 80 percent and you pay 20 percent if you go to an in-network doctor. Out of network, your plan may 60 percent and you pay 40 percent.
    • These plans allow for GAP, out-of-network or a PPO waiver.
    • Most of our patients have these types of insurances.
  • HMO
    • HMO plans do not include out-of-network benefits.
    • These plans need a referral to be seen at an out-of-network provider/laboratory.
    • The patient must initiate the request from their primary care physician.
      • The PCP will request the referral to be seen at Foundation Labs on the patient’s behalf.
  • EPO/self-funded
    • These plans do not have a GAP, out-of-network requests or PPO waivers.
    • Essentially they are CASH patients.
Who can the patient contact regarding an out-of-network request status?

  • The member can follow up with their insurance carrier regarding the status of their out-of-network request.

     

How much will the patient’s maximum bill be if the out-of-network request is not approved?

  • The patient will not pay more than $2,500 for their lab bill per service. 

    • Options for payment:
      • A four-month or six-month payment plan directly with TPIRC Diagnostic
      • Affirm: Multiple payment plan options including six months of interest-free payments https://m.affirm.com/tpirc
      • Caredcredit: Interest-free plans of 6 or 12 months www.carecredit.com
Is there an option to go to another diagnostic laboratory?

  • Unfortunately, no other laboratory is capable of completing all the tests in their entirety at this time.  All blood draws must be drawn and processed through TPIRC Diagnostic.

    Reasons: 

    1. Other laboratories cannot do all of the comprehensive labs that are required by the Food Allergy Institute in their totality. 
    2. TPIRC Diagnostic is one of only three high complexity laboratories in the United States to run these types of high complexity allergy tests (the other two laboratories are academic sites on the East Coast). A standard commercial lab would only run 20 tests of an inaccurate form of blood RAST testing. 
    3. TPIRC Diagnostic runs over 300 blood markers including high complexity component resolved diagnostics which directly feeds applied mathematics algorithms to allow for patient-specific treatment to occur in the Tolerance Induction Program.
    •  
What are the CPT codes that are needed for the lab draw?

  • CPT/Procedure Code Service:

    CPT/ Procedure CodeService
    82784Gammaglobulin (immunoglobulin); IgG 
    82785Gammaglobulin (immunoglobulin); IgE
    82787Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4)
    83520Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified
    85025Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC, and platelet count) and automated differential WBC count
    86001Allergen-specific IgG quantitative or semiquantitative, each allergen
    86003Allergen-specific IgE; quantitative or semiquantitative, crude allergen extract, each-Immunoassay (IA)
    86008Allergen-specific IgE; quantitative or semiquantitative, recombinant or purified component, each
    88184, 88185Urticaria-Induced Basophil Activation
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