Insurance Information

What is your insurance?

Please click on any of the following types of insurance to find out more information about Stanford Medicine Children’s Health’s status with these plans.

Will your insurance company cover your / your child’s visit at Stanford Medicine Children’s Health?

Coverage for your care at Stanford Medicine Children’s Health is determined by your insurance company and is based on the provisions of your specific plan.

We strongly recommend contacting your insurance company directly prior to your visit at Stanford Medicine Children’s Health to verify the following:

  • Is Stanford Medicine Children’s Health part of your insurance plan’s network (=in-network)?
    Your insurance provider may ask you for Stanford Medicine Children’s Health’s group NPI or Tax ID to look up in their system whether we are in-network or out-of-network. Our physicians and hospital each have an NPI and Tax ID number:
    Stanford Medicine Children’s Health Physicians Group NPI: 1417907940
    Stanford Medicine Children’s Health Physicians Tax ID: 26-0089066
    Lucile Packard Children's Hospital Stanford NPI: 1467442749
    Lucile Packard Children's Hospital Stanford Tax ID: 77-0003859

    In general the Physicians Group NPI and Tax ID are needed for outpatient visits and the Hospital NPI and Tax ID are needed for inpatient stays. However, some circumstances dictate using both. We therefore highly recommend confirming with your insurance that both the Physicians Group and the Hospital Tax ID/NPI are in-network

    Please be aware that if Stanford Medicine Children’s Health is out-of-network, you may have a substantial out-of-pocket responsibility.

    To verify Stanford Medicine Children’s Health has in-network status for your plan, you can also look for your plan in the appropriate insurance category above.
  • Are the services you are seeking at Stanford Medicine Children’s Health a covered benefit for your specific insurance plan?
    Health benefit coverage varies with each insurance plan or employer group. Although a Patient Accounts Representative will seek referrals and authorization where necessary, we encourage you to refer to your subscriber handbook or call your insurance directly with questions regarding coverage for specific services. Please be aware that just because your insurance pre-authorized a visit, it does not automatically guarantee that it is also a covered benefit.

Tip: Whenever you speak with your health plan, it is beneficial to write down the name of the health plan representative you spoke with and reference number (if applicable) for future reference.  

Should you have any other coverage/benefit questions after speaking with your insurance about an upcoming appointment, please contact our Financial Counselors at  (650) 736-2273, 8 a.m. – 4:30 p.m.

Insurance Glossary

For more glossary terms, please visit to http://www.healthcare.gov/glossary

Preferred Provider Organization: A type of health insurance plan that contracts with medical providers such as hospitals and physicians to create a network of participating providers. There is a financial incentive to use in-network providers by offering higher benefit coverage than out-of-network providers. Health care services received from providers that are “in-network” are covered at an in-network benefit level, while out-of-network providers are covered by out-of-network benefits, which are typically more expensive.  Patients can typically self-refer to specialists but are responsible themselves for making sure that all providers are in-network.

Exclusive Provider Organization: A type of health insurance plan in which choosing a primary care provider is not required but providers seen must be within the predetermined network.  Out-of-network care is not covered except in an emergency. Patients can typically self-refer to specialists but are responsible themselves for making sure that all providers are in-network.

Health Maintenance Organization: A type of health insurance plan in which choosing a primary care provider is not required but providers seen must be within the predetermined network.  Out-of-network care is not covered except in an emergency. Patients can typically self-refer to specialists but are responsible themselves for making sure that all providers are in-network.

Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.

Co-insurance: The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

Out of Pocket Maximum: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit does not include your monthly premiums. It also does not include anything you may spend for services your plan does not cover.

Referral: A written order from your Primary Care Physician for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your Primary Care Physician. If you do not get a referral first, the plan may not pay for the services.

Authorization: An approval from your health plan for a specific service, usually within a certain window of time. Many plans, including HMOs, require authorizations for all specialist services/procedures.

Primary Care Physician: Health provider that covers a range of prevention, wellness, and treatment for common illnesses. Primary Care Physician include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health-related issues. They may also coordinate your care with specialists.

Specialist: A physician that focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.