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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:

If you have questions about your health insurance plan, please reach out to your insurance provider who can assist you with any questions you may have about your plan.

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Insurance Coverage

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

• Referral requirements
  • 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 on file before scheduling or seeing new patients, even if your insurance company has stated that a referral is not required for specialist visits. A referral details what your condition is, how its progressed and gives us scope on how to approach your healthcare.

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 PCP providers 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.
      • Local PCP Offices Located in:
        • Silverton, Oregon:
          • Legacy Medical Group – Silverton Family Medicine
          • Silver Creek Family Medicine
          • Hope Family Medicine
        • Mt. Angel, Oregon:
          • Legacy Medical Group – Mt. Angel
        • Woodburn, Oregon:
          • Salud Medical Center
        • Salem, Oregon
          • Salem Health (Salem Hospital)
          • Salem Clinic
          • Lancaster Family Medicine
          • WFMC Health
          • West Salem Family Practice
  • *The primary care provider (PCP) offices listed above are provided for patient convenience only, are in no particular order, and are not directly connected with or affiliated with FCSA.

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Screening and Surveillance Colonoscopy Referrals

At this time, our office is no longer accepting new patient referrals for routine screening and surveillance colonoscopies. Screening and surveillance colonoscopies will only be performed for patients who are already established with our practice and have previously been seen by one of our providers.

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.

Other places to inquire about screening colonoscopies include:

• Dr. Roger Epstein – Gastroenterology
• Salem Gastro
• Northwest Gastroenterology Clinic and Endoscopy Center
• Salem Clinic Gastroenterology

The offices listed above are provided for patient convenience only, are in no particular order, and are not directly connected with or affiliated with FCSA.

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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)

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

How long do authorizations take?
Authorization timelines vary depending on the insurance company 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?
In many cases, authorization approval is required before scheduling can be finalized. Patients run the risk of full financial responsibility if authorization is not obtained prior to the procedure.

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 and basic benefits. 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.

Can I be seen for multiple problems during one visit?
Only conditions included on the referral or authorization may be addressed during your appointment. Additional conditions may require and additional referral and consultation visit.

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.