Billing and Financial Information

Billing Frequently Asked Questions

Below are several questions we receive regarding billing. Click on a question to see the answer.

What is an Explanation of Benefits (EOB)?

An EOB, or Explanation of Benefits, is a statement that provides necessary information about claim payment and patient responsibility amounts.

Some of the information you may see on an EOB includes:
  • Provider of care,
  • what services were covered,
  • what amounts were paid,
  • what discounts/adjustments the provider is contractually obligated to write off,
  • which, if any, services were denied by your coverage and why,
  • and your deductible and/or co-insurance and/or co-payment amounts.
Sometimes an EOB is also called on EOP, or Explanation of Payment.

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Can I come in to talk to someone regarding my bill?

Yes, our Patient Financial Service Representatives are here to assist you from 8 am – 4 pm CST, Monday – Friday, excluding all major holidays. You can find our office at 213 E Redwood Ave, Sallisaw, OK 74955.

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Why am I receiving a refund check?

We received an overpayment on your invoice. Either you have paid too much on your invoice and/or your insurance paid at a later date and covered some of what you had already paid.

If you feel that you have received this refund in error, please contact our Customer Service department during normal business hours.

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My insurance paid more than billed charges. Why do I owe anything?

Some insurances pay using the DRG (Diagnosis-Related Group). A DRG payment is one payment by your insurance company for your entire stay. This payment is based on your diagnosis rather than on each individual charge, regardless of the length of stay or what the total charges were. It doesn't matter if the patient stay was 5 days or 30 days, or if the charges were $50,000 or $500,000. The hospital will get paid exactly the same amount.
  • Under your coverage plan, you are still responsible for a co-pay when your insurance pays based on DRG.
  • Please contact your insurance company or review your benefits booklet for more information on your insurance coverage if your personal liability is larger than you expected.
  • Additional Information: When Medicare was established in 1966, the regulations specified that Medicare would not pay charges, but would pay hospitals the cost of services provided. Charges became less important, and attention was focused on the best way to incur and report costs. Insurers and patients still paid charges however, so that in order to make any return on investment (profit) hospitals increased charges above cost. With the advent of Managed Care in the 1980s, insurers also obtained discounts from charges. Medicare changed to the Diagnosis Related Group (DRG) methodology in 1982. This system pays hospitals an amount based on the diagnosis of the patient.
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I don't have any insurance. Is there any help available?

We can assist you in several ways. If you do not qualify for any type of government programs, we can review your financial status to see if you qualify for our Financial Assistance Program.

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Will you bill my primary and secondary insurance?

You will need to provide us with complete primary and secondary insurance information. As a courtesy to our patients, Sequoyah Memorial Hospital submits bills to your insurance company and will do everything possible to advance your claim. However, it may become necessary for you to contact your insurance company or supply additional information to them for claims processing requirements or to expedite payment.

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Why did my insurance company deny the claim?

There are several reasons why your insurance company may deny your claim. One or more of the following may apply:
  • The service you received was not covered under your plan, or
  • you did not provide the correct insurance information at the time of service, or
  • the service you received was from a physician outside of your plan's network, or
  • you were not covered by the plan at the time of service.
The EOB sent to you by your insurance company should explain in more detail why they denied either a portion of the claim or the entire claim. If you receive a denial from your insurance carrier and still have questions, you should contact them to better understand the reason for the denial.

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How do I know if my health plan includes Sequoyah Memorial Hospital?

Sequoyah Memorial Hospital participates in most major health plans in Oklahoma. Please review your health plan provider directory and/or consult with your insurance company to confirm coverage.

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How will Sequoyah Memorial know what insurance I have?

When you register for services at Sequoyah Memorial, please present your current health plan identification card. You may send Sequoyah Memorial your updated insurance information at any time. Either mail to: Sequoyah Memorial Hospital 213 E Redwood Ave, Sallisaw, OK 74955, or send a Fax: (918)-774-9478

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What do "in-network" and "out-of-network" mean?

If you receive your healthcare services from a hospital, physician, or other healthcare provider that participates in your health plan, they are often referred to as "in-network." Hospitals, physicians, or other healthcare providers who do not participate in your health plan may be referred to as "out-of-network."

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I belong to a managed care plan but needed to be seen in the emergency room. What should I do now?

If you did not contact your primary care physician or your insurance company before you came to the emergency room, you will need to contact them within 24 hours of receiving services to explain the circumstances and ask for authorization. The toll free number you will need to call your insurance company is usually found on the back of your insurance card.

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What should I do if my insurance includes Sequoyah Memorial as a participating provider but I receive an EOB stating I am out-of-network?

One or more of the following may apply:
  • The service you received was not covered under your plan, or
  • you did not provide the correct insurance information at the time of service, or
  • the service you received was from a physician outside your plan's network, or
  • you were not covered by the plan at the time of service.
If your EOB states that the services you received were out-of-network, consult your insurance company. If you have further questions about your account, you may also contact Patient Financial Services at 918-774-1100 Ext. 130.

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Why did I receive a bill from my doctor in addition to my hospital bill?

These bills are for professional services provided by doctors who assisted in diagnosing and interpreting test results while you were a patient. Pathologists, radiologists, cardiologists, anesthesiologists, and other specialists perform these services and are legally obligated to submit separate bills. If you have questions about these bills, please call the phone number printed on the statement you received from them.

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I received an EOB from my insurance company. Is this a bill I need to pay?

No. An EOB is simply an explanation of your insurance benefits. If your EOB shows a deductible, co-insurance and/or co-payment amount on it, you will receive a bill from Sequoyah Memorial once we’ve received and posted your insurance company’s payment.

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Why do I have to verify my address each time?

Though address and telephone numbers remain constant for approximately 70% of us, this information changes frequently for others. Verifying this information at each visit is essential in our billing and collection processes.

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Why don't you keep the information available so you can retrieve it without reentering it?

Demographic information is considered valid for a certain period of time. At Sequoyah Memorial, we revalidate contact information daily. However, despite verifying the information, we still receive some mail each week with invalid addresses and phone numbers that are disconnected.

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Why must I show my insurance card each time?

Insurance coverage changes more frequently than addresses. Your card provides the pre-certification telephone numbers, claims address and group numbers that are essential to us as your insurance advocate and to the processing of your insurance claim. As an industry standard, insurance information is considered accurate only at the time of service, thus the need for revalidation each time you are seen. Some insurances require a copy of your card be submitted with your claim.

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But I have Medicare and it does not change. Why do I have to show my card every time?

Information contained on your Medicare card defines the correct billing expectation Medicare requires. While 99% of the time this does not change, our revalidation period necessitates that we renew the information in our system.

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I am retired and have Medicare. When I come in, you ask about me and my spouse's employment status. Why?

Medicare is a "last payer insurance." Federal law mandates that all Medicare providers verify at each visit that you or your spouse does not have an Employer Group Health Plan that would be primary over Medicare. When audited, we have to show proof that for each time you received services, you were asked specific questions relating to the possibility of other insurance. Additionally, if you are in an accident and someone else is at fault, the other party is responsible for your medical expenses according to Federal Law.

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Sometimes I have to wait for medical tests because you need an "order." What is this?

Similar to a pharmacy filling a prescription, a physician's order must be on file requesting a diagnostic test before we can perform a service. If we do not have record of the order and it is not presented at the time of service, we must call the physician's office and request the order be faxed. The results are then directed to the ordering physician who will confer with you regarding the results.

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Diagnosis

All insurance companies require a valid diagnosis to enable them to determine the benefits due. It is the physician's responsibility to provide the hospital with a diagnosis. If you have questions concerning the diagnosis, you should contact you physician directly.

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Screening-Wellness Testing

If you have benefits under your insurance plan that allows for annual wellness or preventative testing it is important that you tell your Physician. Once a claim is filed with your insurance it becomes an historical fact and cannot be changed by the hospital.

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Medicare Patients

The purpose of an ABN is to give the patient notice, before a service is provided, that the hospital believes it is unlikely that Medicare will cover the test, procedure, or therapy that your doctor has ordered. The ABN will list the service, explain why the Medical Center believes Medicare might not pay, and inform you that you will be fully and personally responsible in the event that Medicare does not pay. After being informed that Medicare would not cover a test, if you choose to go ahead and have it, you are accepting responsibility for payment of the service. If an order does not support the medical necessity at the time of the test, it will not support after the test. This can be construed as Fraud & Abuse.

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Commercial Payers

Commercial carriers will ask for the medical records anytime a change in the diagnosis is made to make sure Sequoyah Memorial is not committing insurance fraud by trying to get the member better payment. If the insurance plans only look at the first diagnosis and the diagnosis is coded and on original order, we inform them that this was not correct that all diagnosis needed to be considered. When the diagnosis is not present on the original order it becomes the patient/insured responsibility to work with their insurance carrier to collect the benefits of their insurance plan.

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The Billing Process

Below are questions that we receive specific to the billing process.

Will you bill my insurance?

Sequoyah Memorial will act as your insurance advocate and bill your insurance carrier for services rendered. The hospital expects payment from you or your insurance company within sixty days of discharge. If your insurance has not paid, you should contact them directly.

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Precertification or prior authorization

Many insurance companies now require advance notice of admission or service. You should contact your insurance company immediately when your physician determines that you need to be admitted or have an outpatient service to obtain this authorization. Precertification does not guarantee payment of the bill. The phone number is usually located on the back of your insurance card.

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Coordination of benefits

Group insurance companies coordinate their benefits. This is to reduce duplication of payment for the same service. We ask that upon admission, you give us all insurance information for all policies for which you are eligible for benefits. We will submit this information to your insurance company, who will coordinate the benefits and pay appropriately.

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Third party liability

In cases of injury resulting from an accident, Medicare and Medicaid require that the hospital bill the liable party (car insurance or homeowners insurance) for services before Medicare/Medicaid is billed. Some insurance companies also have this requirement. Again, this is to avoid duplication of payment. Except for Medicare/Medicaid patients, you will need to bill any other party liable for you services.

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My insurance requires a PCP referral whenever I go to the Emergency Room. Who is responsible for obtaining the referral?

It is your responsibility to tell your physician that you were in the Emergency Room, but if your condition requires admission to Sequoyah Memorial or another hospital, your physician will be notified by the hospital. If you do not obtain a PCP referral, you will be responsible for the bill.

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Will you help me with any insurance questions?

The billing staff at Sequoyah Memorial is willing to assist you with any insurance questions. With your approval, our staff of insurance specialists will assist you in the appeal of insurance denials and clarity of payment issues.

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What if I am injured at work?

When you provide correct Workers Compensation billing information, which you will receive from your employer, Sequoyah Memorial will notify your employer and bill them for the services rendered. If your employer denies the claim or fails to pay within 90 days, we will consider the bill due from you. You may, however, request that we submit the claim to your medical insurance at this time. Sequoyah Memorial can only hold a claim if a dispute arises between you and your employer regarding the validity of the worker compensation claim after a claim has been filed with the Oklahoma Worker's Compensation Board

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When Do I Pay? I know that I will owe a deductible or co-pay. When will I have to pay?

Co-pays will be collected at time of service. We will then bill you for any remaining balance on your account after your insurance pays. You can contact our Patient Financial Counselor to set up payment arrangements for any balance that you may owe. If you have questions or need help understanding your bill please call 918-774-1100 and ask for the Patient Financial Counselor.

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I do not have insurance. What options are available to me?

If you meet criteria for coverage, Sequoyah Memorial offers Medicaid application assistance. If you are above the financial guidelines for Medicaid, our external billing office offers payment options. You can call a Patient Financial Officer at 918-774-1100 Ext 603 for more assistance with payment options.

You may apply for Medicaid at ohca.org. Under "Individuals" tab, click "enroll online now". Click "Apply For Benefits", click "I agree", then fill out the online application. At the end of the process, you should be notified whether or not you are approved.

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What if I do not have the money to make monthly payments?

Sequoyah Memorial has a Financial Assistance Policy/Charity Care to assist qualified applicants, depending on income and assets. Applications are available upon request. Once your application is turned in to SMH it will go through a committee to determine if you qualify. It could take up to 6-8 weeks for notification from SMH.

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Why so many bills?

You will be receiving a bill for services provided at Sequoyah Memorial Hospital. Depending on the tests or care you received, you may receive bills from one or more for the following groups:
  • Emergency Staffing Solutions at (800)-225-0953
  • Dr. Winn Group
  • Diagnostic Imaging at (918)-622-0436
  • RML Laboratory/Pathology at (918) 744-2164, or (800) 331-9102
  • Legacy (Family Practice Clinics) contact Casey at (877)-349-9315 ext. 395
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