Understanding Your Health Insurance

There are hundreds of health insurance plans, and each one is different. Before scheduling services at The Children’s Hospital of Philadelphia or at a location within the CHOP Care Network, you should:

Review the list of payors (insurance companies) with which we participate. Please visit "Does CHOP Take My Insurance?" If your plan doesn't appear on this list, call your insurance company to ask if they consider CHOP to be "in-network." You may also call our Pre-Visit Financial Counseling Hotline at 1-800-664-7855 or 215-590-3954.

Find out if your plan requires a referral or authorization. Before your visit, you will need to call your insurance company for specific plan-related questions, such as the CHOP-provided services that require referral or authorization. Your visit may be canceled or rescheduled if authorization is not approved by your insurance company. If your insurance company needs a referral and/or pre-authorization, please call your primary care doctor before scheduling an appointment with us.

Learn more about the charge for your child’s visit to CHOP. Call our Pre-Visit Financial Counseling Hotline at 1-800-664-7855 if you are bringing your child in for outpatient visits. Ask what the fee for the physician office visit may be. We cannot always determine in advance what services you will require and receive, so we may not be able to provide a complete estimate of cost in advance. If you are bringing your child in for an inpatient visit, you will be charged for:

  • The physicians’ time spent examining your child
  • Any procedures/tests that are performed
  • Hospital services including nursing care, supplies, machines, equipment and the use of the Hospital’s facilities.

Find out about the services covered by your insurance plan. Most insurance plans make you pay for your part of the service provided to your child through a “co-pay,” “deductible” and/or “co-insurance.” Your plan may also pay differently for certain CHOP services (such as labs and radiology) or certain CHOP locations, which may affect your financial responsibility. All of these amounts are set by your insurance plan. Please call your insurance company directly for more information.

Be prepared to pay your co-pay or co-insurance at the time of your child’s visit. CHOP accepts payment in the form of cash, credit cards and checks. If our staff is unable to collect your physician and/or hospital co-pay at the time of your visit, you will be billed separately for the applicable co-pay(s).

Let us know if you need help. It is your responsibility to have everything in order by the time you arrive for your child's appointment, but we’re here to help. Counselors who staff our Pre-Visit Financial Counseling Hotline are also available to assist you with your questions and help you understand what is needed for a referral or authorization. Feel free to contact us with any questions at 1-800-664-7855 or 215-590-3954.

Getting answers to your health insurance questions

If you’re unsure about any of the insurance plan features discussed above, the best way to learn about your specific plan is to contact either your employer’s Benefits Office or your health insurance provider. The following list of questions will help you get the detailed answers you need:

First, ask your healthcare provider if it considers CHOP to be in-network or out-of-network.

My child needs services from the Department of _____________ at The Children's Hospital of Philadelphia. (Explain why this is important for your child's care.) I need to understand if my insurance will cover/pay for my child's care at this hospital. Do you consider CHOP and its physician (billing) groups to be “in-network,” a “preferred provider,” a “non-preferred provider,” or "out-of-network?"

If CHOP is in-network, ask your insurance provider the following questions:

  • What are my covered services?
  • What are my covered benefits? When will my coverage begin?
  • What will my cost-sharing responsibility be?
    • Please explain my co-payment (co-pay) responsibilities.
    • Please explain my co-insurance responsibilities.
    • Please explain my deductible responsibilities. How much have I paid towards my deductible so far? How much do I still need to pay?
    • Is there a difference in my cost-sharing/financial responsibility amounts based on services received (i.e., Emergency Department, inpatient, outpatient etc.)?
  • Can my child have labs or other testing done at CHOP? If he or she has these tests done at CHOP, what will my cost-share/financial responsibility be?
  • Questions about my child:
    • How do I ensure that my newborn baby will be added to my plan? What date will that coverage begin?
    • If my child is born with a complication and/or special needs, can the plan refuse the coverage?
    • At what age and under what conditions will my child’s coverage end?
    • Is there anything in this plan about pre-existing conditions?
  • Referrals and pre-approvals/pre-authorizations:
    • Do I need referrals for my child to receive care? For what services? What is the process for getting them?
    • Do I need pre-approval/pre-authorizations for my child to receive care? For what services? What is the process for getting them?
  • Is there a lifetime maximum on this plan? Have I met it or am I close to meeting it? What do I do when I meet it?
  • Tools:
    • What tools can I use to estimate my out-of-pocket costs?
    • Can I view my Explanation of Benefits online to view what I owe, what I have paid and what insurance has paid?
  • For my Employee Benefits Office:
    • Do I have the following and how do I access them?
      • Flexible spending account (FSA) 
      • Health savings account (HSA)
      • Health reimbursement account (HRA)

If CHOP is out-of-network, ask your insurance provider the following questions:

  • Do I need to obtain a pre-authorization so that my child can be seen by a CHOP physician or have labs or other diagnostic tests done by an out-of-network or non-preferred provider (like CHOP)?
  • If so, how do I get that pre-authorization?
  • How much of the cost of the visit(s) and test(s) will I have to pay if I go to an out-of-network or non-preferred provider (like CHOP)? How would this be different if I went to an in-network provider?
  • What information do I tell CHOP about the pre-authorization when I call to make my appointment?
  • Will I need to get this pre-authorization for just the first visit, or will I need it each time if I go back for more visits?
  • In addition to the pre-authorization, will I need to bring a referral from my primary care physician for my child's visit to CHOP?
  • If you do not provide pre-authorization, can I still bring my child to CHOP?
  • My child is seeing providers from more than one billing group (see below) during our visit. Can I check to see if each group is covered, and if I need a separate pre-authorization for each one?
  • CHOP billing groups include:
    • The Children's Hospital of Philadelphia (CHOP)
    • Children's Anesthesiology Associates (CAA)
    • Children's Surgical Associates (CSA)
    • Radiology Associates of Children’s Hospital (RACH)
    • Children’s Healthcare Associates (CHCA)
    • CHOP Care Network Practices (MSO)
    • Children’s Hospital Home Care (CHHC)
    • CHOP Behavioral Health doing business as The Children’s Hospital of Philadelphia Practice Association (in PA)
    • CHOP Behavioral Health doing business as CHOP Clinical Associates (in NJ)

Downloadable resource

Understanding Your Health Insurance Plan (PDF)

Insurance Coverage for Lab Work, Radiology and Other Testing (PDF)

Next Steps
Pre-Visit Financial Counseling Hotline
Questions About Your Bill