🏥Insurance & Authorization Information

Understanding insurance requirements can help prevent delays in scheduling, treatment, and billing. Our office works with many insurance providers, but patients are responsible for understanding their individual plan requirements, coverage, and benefits.

This page provides general information about referrals, authorizations, coverage requirements, and what to expect when receiving care through our office.

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✔️Insurances in Network with Falls Canyon:

*Please note: The list of in-network insurance plans is subject to change and may not include all plans we accept. Patients should always verify network participation directly with their insurance carrier, as many major insurers offer multiple plans and our providers may not be in network with every plan under a particular company.

If you have questions regarding your coverage or network status, please contact your insurance provider. They can provide the most accurate and up-to-date information regarding your specific plan and benefits.

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🛡️Insurance Coverage

Insurance coverage varies by plan. Patients are encouraged to contact their insurance company directly to verify:

• Referral requirements
  • Please Note: We as Falls Canyon Surgical Associates are a referral-based clinic and require an authorized referral on file for all patients regardless of their insurance company.
• Prior authorization requirements
• In-network provider status
• Deductibles, copays, and coinsurance
• Coverage for procedures, surgeries, or testing

Verification of benefits by our office does not guarantee payment or coverage by your insurance company. Patients are responsible for:

• Providing current insurance information
• Obtaining required referrals when applicable
• Understanding their insurance benefits and coverage
• Paying applicable copays, deductibles, and balances

Failure to meet insurance requirements may result in delayed care or out-of-pocket costs.

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📄Referrals

Our office requires a referral from your PCP before scheduling or seeing new patients, even if your insurance company has stated that a referral is not required.

Please note:

• Due to insurance requirements, referrals from emergency rooms and urgent care clinics do not qualify as valid referrals for scheduling purposes. If you were seen in an ER or urgent care, after you are discharged, please contact your primary care provider (PCP) to send us a referral detailing your condition and any relevant imaging, labs, or chart notes.
  • If you are not currently established with a PCP:
    • 1st Option: Call your insurance company who can provide a list of local PCPs in your area that are in-network with your insurance plan and accepting new patients.
    • 2nd Option: Call your local PCP offices and inquire about providers that are taking new patients.

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Screening and Surveillance Colonoscopy Referrals

At this time, our office is not accepting referrals for routine screening or surveillance colonoscopies.

Patients seeking a routine screening colonoscopy who are not established with our office will need to discuss alternative referral options with their primary care provider.

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Due to insurance requirements, providers may only address the condition(s) listed in the referral on file during your visit. Additional concerns or diagnoses not included on the referral may require a new referral and an additional consultation visit.

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📝Prior Authorizations

Some office visits, imaging studies, procedures, surgeries, and medications require prior authorization from your insurance company before services can be performed.

Authorizations are determined by your insurance plan and may require:

• Medical records or office notes
• Imaging or test results
• Documentation of medical necessity
• Review by the insurance company

Authorization approval times vary depending on the insurance provider and type of service requested. Some insurance companies may take up to 30 days for internal review and processing.

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🧾Out-of-Network & Non-Covered Services

Some services may not be covered by insurance or may be considered out-of-network. If this occurs:

• Patients may be responsible for some or all charges
  • Patients will be informed of any non-covered services or denied procedures and may choose to proceed with treatment at their own expense if desired.
• Additional consent forms may be required
• Alternative treatment or referral options may be discussed

Please contact your insurance provider with questions regarding coverage limitations.

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📖Frequently Asked Questions (FAQs)

*The information in this FAQ is for general guidance only and is not medical advice. Please consult your healthcare provider for recommendations specific to your situation.

Why do I need a referral if my insurance says I don’t?
Our office requires referrals to ensure proper documentation, diagnosis review, and insurance processing.

How long do authorizations take?
Authorization timelines vary depending on the insurance provider and type of service requested. Some insurance companies may take up to 30 days for internal review and processing.

Can my procedure be scheduled before authorization is approved?
No, authorization approval is required before scheduling can be finalized.

What happens if my insurance denies authorization?
Your provider may appeal the denial and may submit additional information, discuss alternative options, or recommend further evaluation.

Does insurance verification guarantee coverage?
No. Verification only confirms active coverage. Final payment decisions are made by your insurance company.

What if my insurance changes?
Please notify our office immediately so we can update your information and avoid delays.

Who is responsible for understanding my insurance benefits?
Patients are ultimately responsible for understanding their own insurance coverage and requirements.

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❓Have Questions About Insurance or Authorizations?

Our team is here to help guide you through the insurance and authorization process. Please contact our office if you have questions regarding referrals, authorizations, coverage requirements, or billing concerns.