Your plan type
Find your situation below.
Different plans work differently. Knowing which one you have tells you what to expect from cost-sharing, timing, and any extra steps before a procedure.
Traditional Medicare (Part B) Accepted
The federal program for adults 65+ and qualifying disabilities
Referral needed?
No
You can self-refer to a specialist under traditional Medicare
Prior auth required?
No
Traditional Medicare does not require prior authorization. We confirm in advance that a procedure meets Medicare's coverage guidelines
Typical cost-sharing
20% after deductible
Supplemental (Medigap) coverage may cover this portion
James Lin, MD is a participating Medicare provider. We submit claims directly to Medicare — you don't fill out paperwork. We verify medical necessity documentation before any procedure to reduce the chance of a denial.
Medicare Advantage (Part C) Verify first
Aetna, Humana, UnitedHealthcare, SCAN, Blue Shield 65 Plus, and others
Referral needed?
Depends on your plan
Some require PCP referral; some do not. We check this when you call
Prior auth required?
Usually yes
More frequently than traditional Medicare, and varies by carrier
Typical cost-sharing
Copay or coinsurance
Amount depends on your specific plan's schedule
Important: Medicare Advantage plans are administered by private insurers and network requirements vary significantly. Call us with your plan name and member ID — a five-minute check now prevents scheduling delays later.
Medicare + Medi-Cal (Dual Eligible) Accepted
When you qualify for both programs simultaneously
How it works
Medicare pays first
Medi-Cal coordinates the remaining balance as a secondary payer
Out-of-pocket costs
Zero
Medi-Cal covers the portion Medicare leaves. Your balance for covered services is always zero
Timeline
~3–4 weeks
Slightly longer because two payers are involved; our billing team handles both
If you have both programs, your balance for covered services is zero — you will not receive a bill from us. Our billing team handles the coordination of benefits between Medicare and Medi-Cal on your behalf.
Commercial PPO Verify network status
Employer plans, individual marketplace, Aetna, Cigna, Blue Cross, UHC, and others
In-network vs out
Verify before you come
Network status affects your cost-sharing significantly
Prior auth
Procedure-dependent
Required for most interventional procedures; we handle submission
Out-of-network
Higher cost-sharing
You may receive payment directly from insurer; ABN may be required
Call us with your insurance card information and we'll verify your network status, benefits, and whether prior authorization will be needed for the services you're considering — before you schedule anything.
Network status
Which plans we're in-network with.
Network status affects what you pay. Below are the major carriers — but plans change, and your specific plan may differ from the carrier's general network. Please call us to confirm before you schedule.
In-network
- Aetna Healthcare PPO
- Alignment Health Plan PPO
- United Healthcare PPO and affiliated partners
- Cigna Healthcare PPO
- Curative Health
- Medicare — participating provider
- Medi-Cal as secondary to Medicare
Out-of-network
- Anthem Blue Cross of California
- Blue Shield of California
Out-of-network doesn't mean we can't see you. It means your plan covers a smaller share, and payment may come to you rather than to us.
If your plan doesn't pay: we offer a discounted self-pay rate for our services. Ask us for the figure before your appointment so you know exactly where you stand.
This list covers the major carriers only, and network participation changes over time. Call (805) 557-7050 with your card in hand and we'll verify your specific plan — it takes about five minutes.
Division of responsibility
What we handle so you don't have to.
We handle this
- Verifying your coverage and network status before your appointment
- Confirming Medicare coverage guidelines are met, and submitting prior authorization for plans that require it
- Billing Medicare and secondary insurance (Medi-Cal or Medigap) in the correct sequence
- Following up on pending or denied claims
- Explaining your Explanation of Benefits (EOB) if something doesn't make sense
- Telling you in advance if a service is likely not covered and what the estimated cost would be
What helps from your side
- Bring your insurance card (both sides) to every appointment
- Tell us immediately if your insurance changes — mid-treatment changes affect billing
- Let us know if you receive a payment check from your insurer — for out-of-network situations, payment may go to you first
- Ask before you schedule if you're unsure about your coverage — five minutes on the phone now is simpler than sorting out a bill later
A note on prior authorization timelines
For plans that require prior authorization — Medicare Advantage and most commercial plans — it adds time between when a procedure is recommended and when it can be scheduled. We start the process as early as possible, but we can't always control how quickly an insurer responds. If your situation is urgent, tell us and we will flag it. Traditional Medicare does not require this step.
If prior authorization is denied, we explain why in plain language and discuss next steps — including whether an appeal is appropriate, or whether a different approach would avoid the requirement altogether.
First appointment
What to bring — and why each one matters.
Insurance card (both sides)
We need the member ID, group number, and payer phone on the back to verify benefits
Photo ID
Required for Medicare and most commercial plans at check-in
Imaging on disc or digital
MRI and X-ray images — not just the report. The images are part of prior authorization for most procedures
Medication list
Current prescriptions and doses — relevant to treatment planning and some authorization requirements
Prior treatment records
Physical therapy notes, previous procedure records, specialist letters — these document the conservative care history insurers require
Referral letter (if required)
Only if your plan requires one — we can tell you beforehand whether yours does
Common questions
What patients ask about coverage
Insurance terms explained
Plain-language definitions.
Insurance language was not designed to be clear. Here are the terms that come up most often in pain medicine.
Prior Authorization
Advance approval from your insurer before a specific procedure. Required for most pain procedures. We submit it with your clinical records. Without it, the insurer may not pay.
Medical Necessity
The insurer's standard for whether a service should be covered. Usually requires documentation that conservative treatment was tried and didn't adequately resolve the problem. This is why we ask about your treatment history in detail.
Deductible
The annual amount you must pay out-of-pocket before insurance begins to pay its share. Once your deductible is met, insurance covers its portion for the rest of that calendar year. If you haven't met it yet, you may owe the full cost of early visits — which is why the time of year matters when planning elective procedures.
Copay / Coinsurance
Coinsurance is your percentage share of the Medicare-approved amount after the deductible is met — typically 20% for Medicare patients. A Medigap supplement or Medi-Cal secondary plan often covers this 20%. A copay is different: it is a fixed per-visit fee (e.g., $30) regardless of what services were provided, and is more common in commercial plans than in Medicare.
Out-of-Pocket Maximum
The most you will pay in a calendar year. After this amount is reached, your insurance covers 100% of covered services. Knowing your OOP maximum helps plan for a year of care.
EOB (Explanation of Benefits)
A statement from your insurer showing what was billed, what they paid, and what you owe. Not a bill — a record of how the claim was processed. If yours doesn't match your bill, call us.
ABN (Advance Beneficiary Notice)
A form used when a service may not be covered. It states the estimated cost if insurance denies it and asks you to confirm you understand and choose to proceed. We explain it before asking you to sign.
Coordination of Benefits (COB)
The process when you have two plans (e.g., Medicare + Medi-Cal). One pays first (primary), then the other pays the remaining balance (secondary). Our billing team handles both claims in sequence.
Eligibility Verification
The check we run before your first visit — confirming that your insurance is active, what type of coverage you have, whether your deductible has been met, and whether you have secondary insurance. This is why we ask you to call with your insurance card before scheduling: a five-minute check now prevents billing surprises later.
In-Network vs Out-of-Network
In-network means your plan has a contract with this provider — you pay less. Out-of-network means no contract — you may pay more, and payment may go to you first rather than to us. Call to verify before your appointment.
Noridian Healthcare Solutions
The Medicare Administrative Contractor (MAC) for California — the regional organization that processes Medicare claims on behalf of the federal government. If you receive a letter or EOB from Noridian, it is a legitimate Medicare document related to a claim we submitted on your behalf. Questions about it can be directed to our billing team.
Participating Provider
A provider who has agreed to accept Medicare's approved amount as payment in full. James Lin, MD is a participating Medicare provider, which means you will not be billed more than Medicare's cost-sharing rules allow.
Five minutes on the phone saves a lot of billing confusion later.
Call us with your insurance card and we'll verify your coverage, check whether a referral is needed, and confirm what your plan requires — before you schedule anything. For billing questions, ask for extension 119.