Insurance Coverage

 

Wake Radiology UNC REX is in-network with major insurance plans, including UnitedHealthcare.

 

Affordable, Quality Imaging

At Wake Radiology, we prioritize your well-being and strive to provide the best possible care. By being in-network with major insurance plans, we aim to make our services more accessible and affordable for all patients. Interest-free payment plans and prompt payment discounts are offered through our billing department to help with out-of-pocket expenses for patients.

 

In-Network Insurance Providers

Wake Radiology maintains in-network status with major insurance providers, including UnitedHealthcare.

  • Aetna: Not part of the Duke Select and Duke Basic Network. Members in these networks do not have out-of-network benefits.
  • BlueCross BlueShield of North Carolina (BCBSNC) including but not limited to: Blue Advantage, Blue Care, Blue Options, Blue Select, Blue Value/Blue Value with UNC HA, Classic Blue and North Carolina State Health Plan, BCBS Blue Home with UNC Health Alliance
  • BlueCross BlueShield outside of North Carolina
  • Cigna Health Care / GWH-Cigna: Not part of the Cigna Connect Network. Members in this network do not have out-of-network benefits.
  • UnitedHealthcare –
    • All Savers
    • Community Plan
    • Neighborhood Health Partnership
    • OneNet PPO
    • OptumHealth
    • Oxford Health Plans
    • UMR
    • UnitedHealthcareOne
    • UnitedHealthcare Services Company of the River Valley

Military / Government Plans

  • CHAMPVA
  • Tricare (non-Prime plans): Non-network participating provider.
  • Tricare Prime: Non-network participating provider. Member is responsible for obtaining prime referral to reduce their out-of-pocket expense.
  • Tricare for Life (secondary to Medicare): Non-network participating provider.
  • Veteran Administration (VA): Proper VA referral required.

Medicaid

  • Medicaid of North Carolina

Medicare

  • Medicare Part B

Medicare Part B Supplement Plans

  • All Medicare Part B supplements

Medicare Part C (Medicare Advantage)

  • All Private Fee for Service (PFFS) plans accepted
  • Aetna Medicare Advantage: Not part of the Prime HMO and QHP networks. Members in these networks do not have out-of-network benefits.
  • Blue Medicare
  • First Carolina Care Insurance Company: First Medicare Direct Smart HMO & Preferred Plus, including Alignment Health
  • Humana Medicare: HMO / PPO, including Alignment Healthcare
  • United Healthcare Medicare Solutions

Out-of-Network Resources

Out-of-network refers to a health care provider who does not have a contract with your health insurance plan. At Wake Radiology, we understand that some patients may need out-of-network resources. It’s essential to remember that many insurance plans still offer benefits, even when seen out-of-network. However, it’s important to note that out-of-pocket costs will likely be higher in such cases.

Resources 

  • Managed Care Patient Assistance Program
    Created as part of the NC Patient’s Bill of Rights, the MCPA provides education, advice, support and information for North Carolina consumers with health insurance issues. They provide basic information about how health insurance works, help interpret Explanation of Benefits (EOB) documents and provide direct assistance to those who want to appeal the denial of health care services by their health insurance company. They can be reached at 1-855-408-1212.
  • North Carolina Department of Insurance
    This department educates consumers about different types of insurance, handles consumer complaints and more. Patients can reach NCDOI by phone or online at ncdoi.com.

     

    • Consumer Services
      This division has consultants trained to help the general public with a variety of insurance issues involving auto, homeowners/renters, liability, life/annuities, disability, Medicare supplement, long-term care, dental, vision, hospital, accident, specified disease and other coverages. They answer insurance questions and help educate the public on available avenues to resolve insurance related problems. Call 800-546-5664 or 919-807-6750 or visit their website. However, please note that most health insurance questions should be directed to Health Insurance Smart NC and most Medicare questions should be directed to Seniors’ Health Insurance Information Program SHIIP.
    • Health Insurance Smart NC
      This division is the state’s primary source of health insurance information and assistance for all people not on Medicare. Call 877-885-0231 or visit them online.
    • Seniors’ Health Insurance Information Program
      This division provides free, unbiased insurance advice to seniors and their families. Call 1-800-443-9354 or visit them online.
    • The Consumer Guide to Health Insurance
      This booklet can be accessed on their website.
  • US Department of Labor
    If you are insured as a result of your or your spouse’s employer, your rights under your health plan may be governed by the Employee Retirement Income Security Act (ERISA) under the US Department of Labor. If so, state law will not generally apply to your group health plan and you will need to contact the Department of Labor for information and assistance. The law requires that your plan sponsor provide you with a “summary plan description.” The employer may also be able to overturn a decision of the plan administrator, especially with regard to a medical necessity determination. Call 1-866-4-USA-DOL or visit their website.
  • The Affordable Care Act of 2010
    The ACA health insurance (also known as “Obamacare”) reform legislation was passed by Congress and signed into law by President Obama on March 23, 2010. For more information on how this historic legislation impacts your healthcare, visit their website.

Insurance Coverage for Annual Screenings

Screenings covered by Medicare and private insurance companies require certain criteria to be met. Wake Radiology recommends that patients check with their insurance carrier before scheduling their screenings to confirm coverage and payment. With the exception of an annual screening mammogram, all screening studies performed at Wake Radiology require a signed physician referral – regardless of insurance coverage.

 

Breast Cancer Screenings: 3D Mammography

The 3D portion of your screening mammogram is currently covered by most major insurance carriers, including Medicare and NC Medicaid. We strongly recommend that you verify coverage with your carrier before your appointment. Wake Radiology offers payment plans for all exams, including 3D mammograms. Our breast imaging radiologists believe so strongly in this advanced technology we don’t want costs to keep you from having this potentially lifesaving screening. Wake Radiology is the first outpatient practice in the Triangle to earn the American College of Radiology’s prestigious Breast Imaging Center of Excellence (BICOE) designation.

Women 40 years +: Insurance & screening mammograms

Screening mammograms are addressed by the Affordable Care Act (ACA) of 2010. The ACA health insurance reform legislation was passed by Congress and signed into law by President Obama on March 23, 2010. The ACA (also known as “Obamacare”) outlines the requirements for health plans to cover women’s preventive healthcare services, including screening mammography every 1-2 years for women 40 years and older, without cost sharing. Health plans are required to provide these preventive services only through an in-network provider. A patient’s health plan may allow her to receive these services from an out-of-network provider, but may charge her a fee. Wake Radiology recommends that patients check with their insurance carrier before scheduling their annual mammogram to confirm coverage and payment. 

High-risk patients under 40 years: Insurance & screening mammograms

For women with private insurance, the cost of a baseline mammogram or annual mammograms for younger women who have a family history of breast cancer is typically covered without copayments or deductibles. Wake Radiology recommends that patients check with their insurance carrier before scheduling their baseline or annual mammogram to confirm coverage and payment. 

Medicare coverage for screening mammography

Medicare covers 2D and 3D screening mammography for female recipients as a preventive health measure for the purpose of early detection of breast cancer. Medicare does not require a physician’s prescription or referral for screening mammography. Information about Medicare coverage is available online at medicare.gov or through the Medicare Hotline at 1-800-MEDICARE (1-800-633-4227).    

  • Medicare will pay for a screening 3D Mammogram with no out of pocket expense for patients.
  • Medicare does not pay for screening mammograms for female beneficiaries younger than 35.
  • Medicare will pay for one baseline mammogram for female beneficiaries between the ages of 35 and 39.
  • Medicare covers screening mammography for women age 40 and over on a once per calendar year basis. Once a woman reaches age 40, a screening mammogram has to have occurred at least 11 months after the last covered screening mammogram.

Medicaid coverage for screening mammography

NC Medicaid covers 2D and 3D screening mammography for female beneficiaries as a preventive health measure for the purpose of early detection of breast cancer. Information about Medicaid coverage is available at the North Carolina Department of Health and Human Services

  • Women 20-39 years. Medicaid will pay for one exam annually when the recipient has (this is not an all-inclusive list):
      1. Documented positive BRCA mutation
      2. Personal history of ovarian cancer
      3. Personal history of chest radiation
      4. Personal history of atypical/high risk biopsy(ies)
      5. Strong family history of breast cancer (first-degree relative: mother, sister, daughter)
  • Women 35-39 years. Medicaid will pay for one baseline exam within the five years.
  • Women 40 years and older. Medicaid will pay for one exam annually.

Bone Density Screenings (DXA)

DXA is covered under the Affordable Care Act of 2010, with no cost sharing (ACA covered preventive services for Medicare as of January 1, 2011). Medicare Part B medical insurance covers this once every 24 months or more often if medically necessary. All qualified people with Medicare who are at risk for osteoporosis and meet one of the following five criteria are covered:

  • A woman whose doctor is treating her for estrogen-deficiency and at risk for osteoporosis based on her medical history or other findings.
  • A person with vertebral abnormalities as demonstrated by an X-ray.
  • A person getting steroid treatments.
  • A person with hyperparathyroidism.
  • A person taking an osteoporosis drug.

For patients who do not meet the above criteria, some insurance companies may or may not cover the cost of the scan. Coverage will likely be based on the referring physician’s assessment of a patient’s risk factors. Wake Radiology recommends that patients check with their insurance carrier before scheduling their bone density scan to confirm coverage and payment.

 

 

Abdominal Aortic Aneurysm Ultrasound Screenings (AAA)

Medicare provides coverage for a one-time preventive ultrasound screening for early detection of abdominal aneurysms for at-risk patients. The Affordable Care Act of 2010 covers this exam one time for men of specified ages who have ever smoked. People with Medicare who are eligible for an abdominal aortic aneurysm screening must meet one of these criteria:

  • They have a family history of abdominal aortic aneurysms
  • They are a man age 65 to 75 and have smoked at least 100 cigarettes in their lifetime

This “Welcome to Medicare” screening exam is is covered by Medicare but requires a signed order from a healthcare provider.  When this exam is performed for diagnostic purposes, insurance coverage must be confirmed. Wake Radiology recommends that patients check with their insurance carrier before scheduling their AAA screening to confirm coverage and payment.

CT Coronary Calcium Scoring

Medicare and many insurance companies do not cover coronary calcium scoring. Out of pocket cost is $350 and Wake Radiology requires a signed physician order. Wake Radiology recommends that patients check with their insurance carrier before scheduling their CT coronary calcium scoring study to confirm coverage and payment.

CT Lung Cancer Screenings

Beginning in January 2015 low-dose lung cancer screenings became a covered service by Medicare and commercial insurance carriers through the Affordable Care Act. Coverage criteria varies so Wake Radiology recommends that patients check with their insurance carrier to see if they qualify for this screening. A signed physician referral is required to schedule this exam.

Colon Cancer Screenings: Barium Enemas

Medicare and major insurance companies cover this screening. Wake Radiology recommends that patients check with their insurance carrier before scheduling their this study to confirm coverage and payment.

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