Sidecar Health designed the pre-bill process to help you smoothly access your benefits for non-routine, costly, or complex care scenarios (pre-planned procedures or care expected to cost over your swipe limit).
Note: If you are looking to understand Benefit Amounts or coverage for routine care expected to cost less than your swipe limit (ex: low-cost Rx, provider fee visits, labs, imaging, etc.), pre-bills are not required (or necessary). To look up your Benefit Amount, you can use the Estimate Care tab in the member portal. Contact Member Care at 855-282-0822 with questions on Benefit Amounts or coverage.
Given that pre-bills are new to you and, possibly, your providers, we’ve prepared this guide to break down the following:
- What is a pre-bill?
- When does it make sense to submit a pre-bill?
- What’s required in a pre-bill?
- How to obtain a pre-bill from your provider
- How to submit a pre-bill to Sidecar Health
- Pre-bill and price shopping pro tips
When scheduling a health care procedure, inform your provider that you will be paying in cash and ask that they provide you with what we call a pre-bill. Your provider may understand this as a “good faith estimate”. If your provider asks whether you are insured, inform them you have a major medical plan that bills differently from traditional insurance. That means you will be paying charges upfront using a VISA card and will submit the paid invoice to your insurance company for reimbursement. Your digital member ID card may be helpful to share.
A pre-bill is an itemized list of services, procedures, and drugs along with their associated medical procedure codes (often called CPT codes) and the expected charge for each.
For example, if you’re getting surgery, the pre-bill should include the cost of the surgery, any lab services or tests, and the anesthesia used during the operation.
Below are the main reasons submitting a pre-bill is beneficial:
Pre-bills authorize the Sidecar Health VISA benefit card to swipe for a level higher than your plan's swipe limits.
Your Sidecar Health VISA benefit card can be used to pay for covered services at the point-of-service or point-of-care, up to the swipe limit. There are different swipe limits depending on whether you are in a medical practitioner’s office or a pharmacy. Your swipe limit is stated in your Schedule of Benefits, found in the member portal under “My coverage”.
To use your Sidecar Health VISA benefit card to pay for a covered service expense that exceeds the swipe limit, you must obtain our prior approval to increase the swipe limit for such transaction. When Sidecar Health approves a pre-bill, a one-time swipe above your plan’s Sidecar Health VISA benefit card swipe limit is authorized.
Pre-bills provide an added layer of protection for you against charges for an unplanned procedure during a planned event.
Sidecar Health will protect you from any balance billing for covered services on the final medical invoice that were not on the pre-bill if the services were unplanned and not capable of being anticipated by the Provider.
Pre-bills for non-routine, costly, or complex care scenarios initiate the provider location assistance process.
If the estimated charges for non-routine, costly, or complex care scenarios on the pre-bill exceed the Benefit Amount, our Member Care team will help you find an alternative provider that charges at or below the Benefit Amount. If we cannot find a clinically appropriate provider, we will cover your planned care without any balance billing. Meaning, you don’t owe the difference if the provider price is higher than the Benefit Amount.
Pre-bills provide clarity around your benefits and your coverage.
If you don’t know your Benefit Amounts and are looking to understand your coverage as you shop for care, pre-bills will provide an extra level of transparency so you can shop smarter.
For example, a pre-bill will explain if getting care from your chosen provider will result in you keeping the savings (if your provider charges less than your plan's Benefit Amount) or owing the difference (if your provider charges exceed the Benefit Amount).
As part of this process, an approved pre-bill will confirm the listed care is covered.
What’s required in a pre-bill?
Your pre-bill must include:
- Patient’s name
- Drug name, form, strength, and dosage
- National Drug Code (NDC)
- Amount charged for each prescription
Example Rx pre-bill contents:
Your pre-bill must include:
- Patient’s name and address (including ZIP code)
- Provider name and National Provider Identifier (NPI)
- Date(s) of service
- Procedure codes (your provider will provide CPT, HCPCS, APC, or DRG) for each service
- Reason for the services (including ICD-10 diagnosis codes)
- Amount charged for each service
When getting a pre-bill from a provider, ask them to include any related services charges, such as:
- Physician (professional) fees
- Lab fees/pathologist
- X-Ray or other imaging fees
- Facility charges
- Pharmacy fees
- Hospital-administered drugs
- Other provider fees
- Other services identified by your provider and considered part of or possible during the planned procedure
How to obtain a pre-bill from your provider:
You have options for how to get a pre-bill, depending on the type of care.
- If you’re re-filling an existing prescription and the price hasn’t changed, you can use your previous itemized medical invoice.
- If you don’t have the above items or you’re filling a new prescription, you can use prescription discount sites, like ScriptSave or GoodRx1, and take a screenshot of your pharmacy’s price for the medication. Your pre-bill amount must match the final charged amount. You also may need to submit the Rx from your provider.
- If you can’t use the above options:
- Have your doctor send your Rx to your preferred pharmacy. You can compare different pharmacy’s Rx prices in your Sidecar Health member portal
- Contact or go to your pharmacy and take a photo of the required information on the outside of the bag, including any discounts
- You can always contact Member Care at (855) 282-0822
For other, non-pharmacy medical facilities:
- Call your provider before your visit and ask for an “itemized medical invoice” or “Good Faith Estimate” with all the required information listed above
- Ask for a pre-bill at a pre-service consultation, especially for planned procedures, like non-emergency surgeries. In these cases, try to submit the pre-bill as soon as possible.
Ask your provider for a Good Faith Estimate. Non-pharmacy medical facilities understand this term and are required by law to provide this to patients in writing. Your provider may ask you if you are uninsured or self-pay. You should tell them you have insurance but that you will pay the provider directly and handle submitting the claim to your insurance on your own.
How to submit a pre-bill to Sidecar Health:
- Check you have all the required information for a pre-bill, listed above
- Submit your pre-bill as a new expense and label it “Pre-bill” by renaming the attachment after it’s uploaded
- If the pre-bill amount is authorized, you will receive a confirmation email2 with the authorized swipe amount 3. The authorized amount is based on Sidecar Health Benefit Amounts, not the estimated provider charge amount. Your final charge must exactly match this amount, to the penny.
- Swipe the Sidecar Health VISA benefit card for the exact authorized swipe amount. You will be responsible for paying anything above the authorized swipe amount.
- Ask your provider for the final itemized medical invoice with the required information and submit it as a part of the same expense as your pre-bill.
Pre-bill and price shopping pro tips:
Pre-bill pro tips
- Your pre-bill charge amount must exactly match your actual swipe amount, or you will need a new pre-bill
- For recurring expenses needing pre-bills (like monthly prescriptions), a new pre-bill is required for each swipe
- We recommend submitting a pre-bill as early as possible. For simple procedures such as routine or outpatient procedures, the anticipated pre-bill turnaround time is five business days. For all other procedures, plan for a seven-day processing period.
Price shopping pro-tips:
- While shopping for healthcare services may be a new experience for you, shopping for high-dollar expenses (consumer electronics, rent, cars) is quite common. These are rarely done without comparing pricing alternatives, and healthcare can be the same.
- Things to keep in mind:
- The Sidecar Member Portal has prices that other members have paid in your area
- Our Member Care team is standing by to provide assistance and suggestions 7 days a week.
- (855) 282-0822 TTY: 711
- If services are done at a hospital, most healthcare systems have price estimation tools online. Beginning January 1, 2022, Federal Guidelines require hospitals to provide a Good Faith Estimate to consumers. More information can be found: Federal No Surprises Act
- Hospital System pricing can be complicated and often publish ‘Billed Charges’ that are well in excess of prices that are actually charged. A recent sample of posted charges indicates prices before cash discount can be ten times (10X) what is available to Sidecar Members when they pay upfront.
- Many hospitals require a deposit on services prior to scheduling. This payment can be authorized with a Pre-Bill and made with your Sidecar Health Visa.
- As your provider’s scheduling office about ‘cash pay’ or ‘upfront’ payment discount options.
1 Sidecar Health provides external links for convenience and informational purposes only. Sidecar Health bears no responsibility for the accuracy, legality, or content of the external sites or for subsequent links from an external site. Contact the external site for answers to any questions regarding its content.
2 Your confirmation email will have information on any services we believe should have been estimated on the pre-bill but were not, and therefore will not be protected from unanticipated balance billing. If your confirmation email lists additional expected services, you may submit an updated pre-bill before you obtain care.
3 The authorized swipe amount will equal your plan’s Benefit Amount or the expected billed charges, whichever is lower. In the case your charges for care are lower, the full Benefit Amount will still be applied to your account after we process your final itemized invoice.