Reimbursement Guide for Commercial Insurance
Athena Diagnostics is committed to assisting physicians and health care professionals provide the best possible care for patients. Athena will work with physicians and patients to manage the insurance reimbursement process.
Please review this helpful guide to find out how Athena can assist physicians and commercially insured patients.
In-Network Insurance Plans
Athena Diagnostics is an in-network provider with Blue Cross Blue Shield PPO, POS, Indemnity, and HMO of Massachusetts and New England insurance plans. We also have managed care agreements with several third party payers.
Individuals who have an in-network insurance plan are not required to make any up-front payments to Athena. They would only be responsible for whatever payment is mandated by their insurance plan. Due to variability between insurance plans, we encourage patients and their health care providers to check with their insurance plan to determine what costs, if any, the patient would be responsible for.
Here is a helpful list of questions to ask the insurance company. You will need to know which test is being ordered when you contact the insurance company.
What is the patient responsibility for this test?
The insurance company will need to know the CPT codes for the test. These codes are available on Athena's website at www.AthenaDiagnostics.com or by calling our customer service department.
Do I have coverage for genetic testing?
Ask this question only if the test ordered is a genetic test. Even though your insurance company considers Athena in-network, your specific plan may exclude genetic testing.
Does my insurance plan require me to obtain a prior-authorization to have this test performed?
Most in-network plans do not require this. Contact your insurance provider to be sure.
Out-of-Network Plans
Athena Diagnostics accepts all types of commercial insurance, however, we are not in-network with all insurance plans. Most individuals with an insurance plan that is out-of-network are eligible for Athena’s Patient Protection Plan (PPP). This program limits patient cost to 20% or $500 (whichever amount is less) for any of Athena’s tests. For eligibility details and enrollment information, please visit www.AccessAthena.com.
For those individuals who have an out-of-network insurance plan, Athena will do the following:
- File claims directly with ths insurance company
- Regularly file appeals on behalf of the patient if coverage is denied
- Assist patients in resolving coverage issues
- Offer flexible payment options if patient must be billed
- Provide resources to help you obtain prior authorization from the insurance company
- Complete CMT Letter of Medical Necessity - Use this if the test being ordered is Athena's Complete CMT Evaluation, #404.
- Generic Letter of Medical Necessity - Use this for all other tests.
Here is a helpful list of questions to ask the insurance company. You will need to know which test is being ordered when you contact the insurance company.
Athena is out-of-network. Do I have out-of-network benefits on my plan, and if so, how much will you cover?
What is the patient responsibility for this test?
The insurance company will need to know the CPT codes for the test. These codes are available on Athena's website at www.AthenaDiagnostics.com or by calling our customer service department.
Do I have coverage for genetic testing?
Ask this question only if the test ordered is a genetic test. Even though your insurance company considers Athena in-network, your specific plan may exclude genetic testing.
Does my insurance plan require me to obtain a prior-authorization to have this test performed?
Patient Protection Plan
The Patient Protection Plan (PPP)* is an optional program available to patients who have a commercial insurance plan that is not contracted with Athena. The PPP limits patient cost to 20% or $500 (whichever amount is less) for any of Athena’s tests.
For Patients Who are Ineligible for the Patient Protection Plan
Athena will file claims and appeals with the insurance company. To help with reimbursement, you may use a letter of medical necessity to obtain a pre-authorization from the patient’s insurance company. To customize the letter, click here.