Policies

Insurance Card Requirement:

You must show your current insurance card at every visit to protect you from receiving a bill due to incorrect insurance information. We will attempt to validate your insurance benefits at the time of service and alert you to any problems. If we cannot validate your coverage, we may assign your account to self-paid status and request full payment at the end of your visit.

Know Your Insurance Benefits:

Your insurance policy is a contract between you and your insurance company, even if your employer provides it. It is important to understand the specifics of your plan, including knowing what services are covered, the extent of coverage, and how much of the cost is your responsibility. You will be responsible for any portion of the services that your insurance doesn’t cover or for which you have a deductible that has not yet been met. You should also know where your insurance wants you to go for lab or radiology procedures to avoid receiving a bill in urgent situations. Key components of your plan include:

• Deductibles: The amount you must pay out-of-pocket before your insurance begins to cover services.
• Copayments: A fixed amount you pay for a covered healthcare service, usually when you receive the service.
• Coinsurance: Your share of the costs of a covered healthcare service, calculated as a percentage of the allowed amount for the service.
• Coverage Limits: The services and procedures covered by your insurance plan, and the frequency of coverage (e.g., well visits).
• Out-of-Pocket Maximums: The most you have to pay for covered services in a plan year.

Newborn Enrollment:

Your insurance carrier may tell you that your child will be covered for the first 30 days. However, this means you have 30 days to enroll your child on your insurance plan to be eligible from their date of birth. If you start the enrollment process after the 30-day grace period, your child will not be eligible until the paperwork is complete, and you will be responsible for any charges incurred from birth to your insurance coverage effective date.

CenCal Health/Medi-Cal:

CenCal in San Luis Obispo and Santa Barbara County is an HMO plan that requires you to assign your child to a Primary Care Physician (PCP). The assigned PCP manages all your child’s care, and any healthcare services from other providers will require a referral from your PCP. If your child is not assigned to Central Coast Pediatrics as their PCP, we cannot provide services. In order to not be reassigned and to maintain your CenCal coverage, please read any paperwork from CenCal thoroughly and complete any required sections.

HMO Plans (Blue Cross, Blue Shield, Aetna, Cigna):

If you have a private or employer group HMO plan, you will need to assign your child to a Primary Care Physician. You will have two provider medical groups to choose from: Coastal Communities Physician Network (CCPN) and Physician’s Choice Medical Group (PCMG) of SLO or Santa Maria. The assigned provider is the gatekeeper to all your child’s care, and any healthcare services needed by any other source will require a referral from your PCP. If your child is not assigned to a physician at Central Coast Pediatrics, we will not be able to provide services to your child.

Combined Appointments:

If you discuss an issue during a well visit that isn't related to the well visit, a sick visit may be added to your appointment. Your insurance may require a copay for the sick visit, which we are required to charge. If an issue cannot be addressed within the time allotted for the well visit, or if you schedule an appointment for one concern but bring up a different issue, you may need to reschedule so the provider can give adequate time and attention to your concerns.

Referrals and Authorizations:



As your pediatrician, we may need to make referrals to specialists and coordinate other services for the total care of your child. Your plan may require that your pediatrician serve as a "gatekeeper" to authorize or approve certain services. Many of these referrals require an initial visit with your PCP before a referral can be issued. Without these approvals, you may have to pay for part or all of these services yourself. In order to process these referrals, we need to ensure that we have the most up-to-date insurance information on file at every visit. 

If you have any questions about the above information or any uncertainty regarding insurance matters, please contact our billing office at 805-549-0888, option 8. We are here to help.

We are committed to providing you with the best possible care. In order to achieve these goals, we need your assistance and your understanding of our payment policy.

Payments for services are due at the time services are rendered unless other arrangements have been made with the business office. Patients participating in PPO/HMO plans must make their co-payments at the time services are rendered. Proper insurance information must be provided to prove eligibility. If eligibility cannot be verified at the time of service, payment in full will be expected.

Medicaid patients must prove eligibility with Central Coast Pediatrics for the current month of service at each visit. WE WILL BE UNABLE TO PROVIDE CARE TO YOUR CHILD IF THEY ARE ASSIGNED TO ANOTHER PROVIDER. All patients who are Medicaid pending status must present proof of application at time of service or payment will be expected.

Not all services are covered benefits in all insurance contracts. Please review your insurance plan so that you are aware of what to expect. You will be expected to make payment on non-covered services at the time they are received.

After discussion and consent with your physician in regards to administering vaccines you will incur a charge for any vaccines that have been drawn up and you choose not to administer. This charge may not be submitted to any insurance company and will be paid in cash. 

We are happy to have engaged the services of a group experienced pediatric nurse advice specialist to assist us in handling your child's urgent medical need that may occur during evening, nights, weekends, and holidays. In order to provide this expanded service financial support is necessary. Insurance does not cover this service, thus our office will be adding a $25.00 charge for each time the nurse specialist or the physician is accessed. We cannot bill your insurance for this service and payment will be required. Our goal is to provide the best and most timely care possible and feel there is tremendous value in having well trained pediatric nurses offering advice whenever the office is closed.

We reserve the right to place a $50.00 charge for broken appointments and appointments canceled without 24 hour advance notice. Patient's arriving more than 15 minutes late for a scheduled non-urgent appointment will be asked to reschedule and may be subject to broken appointment charges. After three fail to keep appointments the patient is subject to possible discharge from practice.



We realize that temporary financial problems may affect timely payment and we will be happy to assist you in the management of your account. If you have any questions about the above information or any uncertainty regarding insurance matters, please don't hesitate to ask us, we are here to help.

Due to the rising practice expenses and the demands placed on our staff in handling the increasing volume of paperwork, we would like to remind you of some charges:

WE REQUIRE 24-48 HOURS FOR ANY REQUEST OF COPIES AND SIGNED FORMS; PARENT PORTION OF FORMS MUST BE PRE-COMPLETED IN ORDER TO BE ACCEPTED

In the event that a parent is unable to bring their child for their visit, it is necessary for a permission note to be sent with the caretaker for each occurrence. This form may be downloaded from our website or if unable to print, a hand written letter will be accepted.

The verbiage in this letter should essentially give our practitioners and your caretakers the authority to bring your child in and make medical decisions on your behalf. If we do not receive this authorization in writing we will not be able to proceed with the care that your child needs without speaking to you, the parent or legal guardian. 

Please allow 7 to 10 business days for your referral to be submitted and approved by your insurance company. If you have not been contacted with your referral/authorization information after 10 business days, please contact our office and speak with our Referral Coordinator.

For URGENT Referrals: Please allow 2 to 3 business days. (Depending on your insurance and if authorization is needed)

Pursuant to Assembly Bill (AB) 1278, Central Coast Pediatrics is required to inform you of the Open Payments Database and provide an accessible link. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided above. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

If you have any questions or concerns, please do not hesitate to ask.

Thank you for choosing Central Coast Pediatrics