Navigating Your Care: Insurance, Billing & Beyond

We know from our members that navigating health insurance and medical billing is one of the most stressful parts of seeking care. The system is undeniably confusing, and while we can’t change the way it's built overnight, we can empower you with the knowledge to navigate it with confidence.

From how to prepare for your visit to what to expect when the bill arrives, this guide is designed to demystify the process. We’ve gathered the most important "Tia Tips" to help you understand your benefits, maximize your coverage, and ensure your focus stays exactly where it should be: on your health.

Check if your insurance is accepted

Navigating Your Care: Insurance, Billing & Beyond

We know from our members that navigating health insurance and medical billing is one of the most stressful parts of seeking care. The system is undeniably confusing, and while we can’t change the way it's built overnight, we can empower you with the knowledge to navigate it with confidence.

From how to prepare for your visit to what to expect when the bill arrives, this guide is designed to demystify the process. We’ve gathered the most important "Tia Tips" to help you understand your benefits, maximize your coverage, and ensure your focus stays exactly where it should be: on your health.

Check if your insurance is accepted

Before Your Visit (Know Before You Go)

How do I know if I’m covered by insurance?

"Covered by insurance" does not mean "paid for by insurance."

When a service is "covered," it simply means your insurance company has negotiated a lower, discounted rate with us and agrees to apply that expense toward your deductible, coinsurance, or copay.

Preventative vs. Diagnostic Visit Coverage:

  • Preventive care: Typically fully covered without cost-sharing (e.g., annual physicals, vaccinations, and some screenings).
  • Diagnostic care: Any service aimed at diagnosing or treating a specific condition (e.g., lab tests, imaging, specialist visits) will usually require out-of-pocket costs.
See If You're in Network

"Covered by insurance" does not mean "paid for by insurance."

When a service is "covered," it simply means your insurance company has negotiated a lower, discounted rate with us and agrees to apply that expense toward your deductible, coinsurance, or copay.

Preventative vs. Diagnostic Visit Coverage:

  • Preventive care: Typically fully covered without cost-sharing (e.g., annual physicals, vaccinations, and some screenings).
  • Diagnostic care: Any service aimed at diagnosing or treating a specific condition (e.g., lab tests, imaging, specialist visits) will usually require out-of-pocket costs.
See If You're in Network

The Good News: Tia Accepts Most PPO Insurance

Insurance Accepted by State:

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Important Disclaimer:

Tia is currently out-of-network for all HMO plans; however, we are happy to see HMO patients via self-pay/cash-pay rates.

Unfortunately at this time due to legal requirements, we are unable to provide care to Medicare/Medicaid/Medi-Cal beneficiaries even on a self-pay basis.

We know this may be disappointing. Expanding access to Tia's care for more women is something we're actively working toward, and we hope to welcome you in the future

Don’t have insurance?

See cash prices for Los Angeles, San Francisco, New York, and Arizona

* Important Notice regarding Anthem / Blue Cross Blue Shield / Empire and Mount Sinai NYC

How to avoid unexpected bills during preventive visits

Save Symptoms for a Separate Visit

Good news - for those with in-network insurance, your Annual Exam/Well Woman is covered at 100% and keeping it that way is simple. Because insurance plans require these visits to be strictly preventive, any specific concern (a UTI, new pain, or fatigue) is best handled at a separate Sick Visit. That way there are no billing surprises, and your concern gets the dedicated time it needs.

Ask Us to Keep It Preventive

If a new symptoms or concern pops up during your Annual Exam, just tell your provider, "I'd like to hold off on discussing that for today to keep this visit purely preventive." We completely understand and are here to help.

Know the Difference in Advance

If you're coming in for an Annual Exam but also want to check on a chronic condition (like PCOS), insurance will likely reclassify that portion of your visit as a "problem visit", which means an additional charge on your end.

Tia Tip

Questions to ask your insurance provider for preventative care:

  • Does my insurance plan cover preventive care at 100%?
  • What preventive services are covered under my plan?
  • Are there limits on how often I can receive these services?
  • What specific screenings, vaccinations, or lab tests included?
  • What happens if a preventive visit becomes diagnostic?
See if you're in network

Cost-Sharing: The Big Four Explained

When you use your health insurance, you are responsible for paying a portion of the total cost. This is called cost-sharing.

Term
What It Is
How it Works
Deductible
The total amount you must pay for covered services before your insurance company starts to pay for anything other than preventive care.
Example: If your deductible is $2,500, you pay the first $2,500 in medical bills for the year. Once you hit that number, the insurance "kicks in" and starts paying a share. Your deductible resets every year.
Copayment (Copay)
A fixed, flat fee you pay for certain services. This is usually due at the time you receive care.
Example: A $30 copay for a regular visit. Your copay may be required even before you meet your deductible, and it usually counts toward your Out-of-Pocket Maximum.
Coinsurance
Your share of the costs of a covered service, calculated as a percentage (e.g., 20%). This applies after you meet your deductible.
Example: If you have 20% coinsurance and a procedure costs $1,000, you pay $200, and your insurance pays $800. This is how you and the insurer "share" the rest of the cost.
Out-of-Pocket Maximum
The absolute most you will have to pay for covered health services in a plan year.
Once your payments (deductibles, copays, and coinsurance) total this amount, your insurance covers 100% of all covered services for the rest of the year. It's the ultimate financial safety net.

During Your Visit

What is the difference between Problem Visits vs. Preventative Care?

  • Preventive Care: Focuses on staying healthy (e.g., annual screening tests, health risk assessments).
  • Diagnostic Care: Focuses on figuring out or treating a specific problem or symptom (e.g., "Why does my ankle hurt?" “My periods have gotten really irregular”).

Most in-network insurance plans cover many preventive services at 100%, including:

  • Annual well-woman exams
  • Cervical cancer screenings (pap smears)
  • Blood pressure, diabetes, and cholesterol tests
  • STI screenings
  • Immunizations

However, most in-network insurance do not cover diagnostic services during preventive exams, which will incur extra cost.

During Your Visit

What is the difference between Problem Visits vs. Preventative Care?

  • Preventive Care: Focuses on staying healthy (e.g., annual screening tests, health risk assessments).
  • Diagnostic Care: Focuses on figuring out or treating a specific problem or symptom (e.g., "Why does my ankle hurt?" “My periods have gotten really irregular”).

Most in-network insurance plans cover many preventive services at 100%, including:

  • Annual well-woman exams
  • Cervical cancer screenings (pap smears)
  • Blood pressure, diabetes, and cholesterol tests
  • STI screenings
  • Immunizations

However, most in-network insurance do not cover diagnostic services during preventive exams, which will incur extra cost.

Not sure where to start?

"I have a specific concern."

Examples: You’re experiencing a new symptom, feeling unwell, or have a specific health problem you want to discuss.

→ RECOMMENDATION: New Patient Visit

Book new patient visit

"I’m due for a check-up"

Examples: You're feeling good and are looking for your annual exam, preventative screenings, or a general wellness check up.

→ RECOMMENDATION: Annual Exam

Book annual exam

Specialty Care & Referrals

What if I need a referral for specialty care?

Tia partners with some of the nation’s leading specialists and hospital systems, including Cedars Sinai, UCSF, and Dignity Health. When you need care outside of Tia’s primary care scope, we ensure the experience is connected, not fragmented.

How It Works:

Consultation

Your provider will discuss the clinical need for a referral during your visit.

Coordination

Depending on your specialty needs, your membership tier, and insurance plan, we’ll either place the referral for you or guide you on how to find an in-network provider.

Closing the Loop

After your specialist visit, you’ll meet back with your Tia provider. This is a critical step where we integrate their findings into your personalized care plan, ensuring your health journey stays on track.

Common Specialty Referrals:

  • Gastrointerology
  • Dermatology (complex cases)
  • Gynecological surgery
  • Cardiology & Endocrinology
  • ENT (Ear, Nose & Throat)
  • Mental Health (Psychotherapy or stimulant medication management)
  • Physical therapy
See If You're in Network

After Your Visit (Payments & Reimbursements)

How Billing Works

This is how medical billing works across all healthcare providers, not just with Tia. Understanding this process can help you feel informed and prepared.

  1. The provider submits a claim: After your appointment, the provider’s office will submit a claim to your insurance company, detailing the services provided.
  2. Insurance processes the claim: Your insurance company will review the claim and determine what is covered under your plan. This is where they apply their rules about preventive vs. diagnostic care, copays, and deductibles.
  3. You receive an Explanation of Benefits (EOB): The EOB is a statement from your insurance company that explains what they paid for and what portion of the bill you’re responsible for. It’s important to remember that the EOB is not a bill, but it gives you a breakdown of the charges.
  4. The provider sends you a bill: If your insurance didn’t cover the entire cost of the visit, you will receive a bill from the provider, indicating what you owe.
See if you're in network

How Billing Works

This is how medical billing works across all healthcare providers, not just with Tia. Understanding this process can help you feel informed and prepared.

  1. The provider submits a claim: After your appointment, the provider’s office will submit a claim to your insurance company, detailing the services provided.
  2. Insurance processes the claim: Your insurance company will review the claim and determine what is covered under your plan. This is where they apply their rules about preventive vs. diagnostic care, copays, and deductibles.
  3. You receive an Explanation of Benefits (EOB): The EOB is a statement from your insurance company that explains what they paid for and what portion of the bill you’re responsible for. It’s important to remember that the EOB is not a bill, but it gives you a breakdown of the charges.
  4. The provider sends you a bill: If your insurance didn’t cover the entire cost of the visit, you will receive a bill from the provider, indicating what you owe.
See if you're in network

How Lab Billing Works

While your lab sample is collected right here at Tia, the actual testing and billing are handled entirely by our third-party partner, Quest Diagnostics (or Quest/Sonora in Arizona). Your lab work is billed by Quest/Sonora, not by Tia. Quest is the one who sets the fees and then charges your insurance where applicable. We collect your labs at Tia for your convenience, so you don't have to make an extra stop!

How You Will Be Billed for Lab Work

Tia does not control the cost of labs or how your insurance chooses to cover those labs. This is all between you, Quest, and your insurance plan.
Because of this system, you should expect to receive two separate bills after your visit.

Who to Contact for Lab Bill Questions

Since they run the tests, Quest is the one who has all the details about the charges and is responsible for billing your insurance for the lab work.
For any questions about the lab charges, coverage, or your Explanation of Benefits (EOB) related to the tests, please contact Quest/Sonora directly.

Tia Tip

You will receive two separate bills for your visit because Tia and the lab (Quest/Sonora) are separate entities.

  • Bill 1 (Tia): Covers your actual appointment and time with the clinician.
  • Bill 2 (Quest/Sonora): Covers the processing of your lab tests.

Lab pricing: Tia does not set lab prices or control insurance coverage for tests.
Billing Issues: If you have questions about a lab charge, you must contact Quest/Sonora directly, as Tia cannot access their billing systems.

You can check with your insurance provider and Quest beforehand if you want to know the exact cost of a test before it’s collected.

See If You're in Network

Payment Methods, Superbills, and Claims

Credit or Debit Card

All major credit and debit cards are accepted through our secure payment portal.

HSA/FSA Accounts

Tia TIP: Generally, medical services (such as sick visits, imaging, and bloodwork) are eligible for HSA/FSA reimbursement. However, membership fees and non-medically necessary wellness services (like aesthetic skincare) are typically not covered. We recommend checking with your plan administrator for specific eligibility.

Superbills & Claims

If you are seeing us as an out-of-network provider, you may be eligible for reimbursement from your insurance company.

How To Obtain a Superbill

A superbill is a detailed, itemized receipt that includes the necessary medical coding (ICD-10 and CPT codes) for your insurance provider.

  • Log into your member portal
  • Send a chat to your Care Team requesting a superbill for the selected visit.

How To Submit a Claim for Reimbursement

  • Download your superbill from Tia
  • Obtain a claim form from your insurance provider’s website (often found under “member forms”)
  • Submit the documentation via your insurance portal or their 3rd-party claims app.
  • Keep a copy of what you send for your records

What To Do if a Claim Is Denied

Denials are common and are sometimes due to simple clerical errors

  • Check the EOB: Reviewing your Explanation of Benefits (EOB) to see the specific “Reason Code” for the denial.
  • Verify Information: Ensure you name, DOB, and Member ID on the claim match your insurance card exactly
  • Request an Appeal: In some cases and depending on the level of clinical appropriateness, Tia can support you with a Letter of Medical Necessity to support an appeal.

Affordability and Payment Plans

We understand healthcare costs are a lot that’s why Tia offers Predictable Payment.

What is Predictable Payments?

Predictable Payments is our new capped invoicing system that ensures that no matter the total amount you owe, you will only ever be billed $100 per month until your balance is paid off. Depending on the care you receive, this could look like: the total amount owed for care might be $300, but the total due this month is $100. This method offers a clear, manageable way to handle medical expenses, allowing you to focus on what truly matters—your health.

What is Predictable Payments?

Predictable Payments is our new capped invoicing system that ensures that no matter the total amount you owe, you will only ever be billed $100 per month until your balance is paid off. Depending on the care you receive, this could look like: the total amount owed for care might be $300, but the total due this month is $100. This method offers a clear, manageable way to handle medical expenses, allowing you to focus on what truly matters—your health.

Benefits of Predictable Payments:

1. $100 Capped Invoices

One of the biggest benefits of this payment method is predictability. With a consistent $100 cap, you can budget with confidence and avoid fluctuating or surprising bills. We know that some months you may need more time to pay, and that’s ok. Our goal is to remove financial stress so you never delay the care you need.

2. One Invoice, One Time a Month

The healthcare billing process can be complicated and confusing. Our new method simplifies this by providing clear, straightforward billing. You’ll receive a single, predictable invoice each month, making it easier to understand and manage your healthcare expenses.

3. Surprise-Free = Stress-Free

Medical expenses can be overwhelming, especially when they come as a surprise. Our capped invoicing system alleviates this stress by spreading out payments into smaller, more manageable amounts. This approach helps prevent financial strain and ensures you can maintain financial stability.

4. Decision-Making For Your Health, Not Your Wallet

We believe in empowering our members with the tools and resources they need to make informed decisions about their health. Capped invoicing is part of our commitment to transparency and member-centric care. We aim to partner with you not just around the care you receive but also how you budget for the costs associated with the care you need and deserve.

Want to know more about Predictable Payments?

Learn more
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Top Insurance FAQ

How do I know if you take my insurance plan?

To check if your plan works with Tia, go to our Join Page. Once you enter your information on in Step 1, you’ll be able to check if Tia takes your plan in Step 2. Don’t worry, this will not commit you to a membership (that happens in the later steps).

Can I join Tia if I don't have insurance?

Yes! You can join Tia with or without insurance. If you do not have insurance, you can pay cash for services. However, we cannot accept members with Medicaid or Medicaid managed plans as we are not in-network with Medicaid.

Can I use an HSA or FSA for my membership?

While we don't accept FSA/HSA cards for membership fees, you can use them for appointments and services by sending itemized receipts for reimbursement to your FSA/HSA provider.

Talk to Our Team

Have questions about Tia’s care?

Speak with a member of our Engagement Team at 646-650-5337