Navigating insurance coverage can be confusing, but knowing what to ask can make a big difference.
General Tips for Insurance Calls
Have your insurance card ready.
Take notes during the call.
Ask for a call reference or confirmation number.
Request an email summary if available.
Write down the representative’s name and last initial.
When speaking with your insurer, be clear and specific—have details like provider names, service types, and dates ready. Don’t hesitate to ask follow-up questions if anything is unclear, and always request written confirmation of coverage when possible.
Helpful Guidelines for Verifying Coverage
Why Verify
You may need to call your insurance to confirm if your Circle Medical provider is in-network with your insurance plan.How to Verify
Use the Member Services number listed on the back of your insurance card.What to Ask When Verifying
We recommend asking questions like: “Can you confirm if Circle Medical is in-network with my plan?”Be sure to write down:
Your representative’s name(s) and initial(s)
Call reference number
Information You May Need
Healthcare Provider’s NPI:
To retrieve this number, contact our Patient Care support team through the app for assistance
Important Terms For Your Call
“Coverage”: What services your plan pays for (fully or partially)
“Deductible”: What you must pay out-of-pocket before your insurance starts covering services
“Copay”: Fixed amount you pay (e.g., $20 per visit)
“Coinsurance”: A percentage you pay (e.g., you pay 20%, insurance pays 80%)
“Telemedicine”: Virtual appointments and visits with your provider
Ask if virtual visits are covered under your plan.
“Wellness Exam Coverage”: Insurance coverage for Annual Wellness Exams
Ask if virtual wellness exams (also known as "annual physicals") are covered annually to confirm that your coverage isn’t restricted to in-person appointments.
“Pharmacy Benefit Managers (PBMs)”: Companies that administer prescription drug benefits for insurance plans. They handle tasks like processing claims, negotiating drug prices with pharmacies, and managing drug formularies
Common Scenarios for Verifying Insurance
You may also need to call your insurance if:
You want to confirm information about your pharmacy benefits.
You want to check if a medication is covered.
We need more information to submit a prior authorization (PA) (or you’re checking on its status).
Below are some specific tips to help you through these cases.
1. Pharmacy Benefits Information
Look for a number labeled Pharmacy Member Services or Member Services on your card.
Ensure you have the following information readily available:
Full name
Date of birth
Member ID
Zip code
Ask your insurance provider questions, such as:
"Who manages my pharmacy benefits?”
“Can you confirm my Pharmacy Benefits Manager (PBM)?”
Examples of PBMs:
CVS Caremark
OptumRx
Express Scripts
Prime Therapeutics
CarelonRx (Anthem)
MedImpact
RxBenefits
Write down the following pieces of information:
Group Number (also known as a Pay-Direct number, this is a unique identifier linked to your group benefits plan)
Member ID (for pharmacy benefits)
Rx BIN (the Bank Identification Number routes a prescription claim towards the right insurance)
Rx PCN (the Processor Control Number further narrows the claim to the specific insurance)
2. Medication-Specific Coverage
Insurance companies are best equipped to confirm your medication coverage.
Ask your insurance provider questions, such as:
“Is [medication name] covered by my plan?”
“Are there any alternative covered medications for [diagnosis]?”
“Does this medication require prior authorization?”
Even if a medication is listed as “covered,” prior authorization may still be required. Coverage also depends on meeting the insurance company’s criteria for your specific condition.
3. Prior Authorization (PA) Status
Insurance companies are best equipped to confirm your PA status as they may have updates before we do.
During your call with your insurance, some information you might want to share is your account and member information and the specific medication name you’re calling about.
Ask your insurance provider questions, such as:
“Can you provide the status of the prior authorization for [medication name]?”
Insurance calls can feel overwhelming, but having the right questions and information ready can make a big difference. Don’t hesitate to ask the representative to slow down, repeat something, or explain a term you don’t understand. It's their job to help you.
If you need support after your call, you can always reach out to our Patient Care team through our HIPAA-compliant mobile app or web portal.