Take control of your coverage. Asking the right questions on your call ensures you receive accurate information and full clarity.
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.
Essential Checklist for Insurance Calls
Preparation (Before you Call):
Have your insurance card(s) ready (Medical & Pharmacy).
Find your provider's NPI (National Provider Identifier) on our insurance page.
Have the specific medication name or health concern ready if checking coverage/Prior Authorization (PA) status.
During the Call (Action Items):
Take notes on all information discussed.
Always Ask For:
The representative’s name and last initial.
A call reference or confirmation number.
Written confirmation (email or letter) of coverage decisions.
Remember: Don't hesitate to ask them to slow down or explain a term you don't understand.
For any call, 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.
Confirming Insurance Benefits for your Care
Why Verify
Your insurance can confirm if your Circle Medical provider is in-network with your insurance plan, as well as if you have benefits for your specified appointment type.
Your insurance will be able to explain out-of-pocket costs.
How to Verify
Use the Member Services number listed on the back of your insurance card.
Essential Questions to Ask When Verifying
Can you confirm if Circle Medical is in-network with my plan?
Is the health concern I'd like to discuss during my appointment(s) covered under my plan?
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.
Coverage for Medications and Prior Authorization
You may 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).
1. Pharmacy Benefits Information
Look for a number labelled Pharmacy Member Services or Member Services on your card.
Ensure you have your information ready:
Full name
Date of birth
Member ID
Zip code
Ask your insurance questions, such as:
Who manages my pharmacy benefits?
Can you confirm my Pharmacy Benefits Manager (PBM)?
Examples of Pharmacy Benefits Managers: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 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 questions, such as:
Can you provide the status of the prior authorization for [medication name]?
If you need support after your call, you can always reach out to our Patient Care Advocate team through our HIPAA-compliant mobile app or web portal.