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Proposed Treatment & Financial Policy Deposit Example

Patient's Responsibility with Insurance Coverage

Due to the variable nature of insurance reimbursement and authorization, patients are responsible for contacting their insurance carrier for coverage and payment. Our services are generally approved by insurance carriers for medical necessity. The typical CPT Codes for our services include: 96116, 90834 & 96118.

Insurance Carrier Disclaimer: “A coverage determination, prior authorization, or certification that is made prior to a service being performed is not a promise to pay for the service at any particular rate or amount. The patient’s summary plan description governs amount payable, as every claim submitted is subject to all plan provisions, including, but not limited to, eligibility requirements, exclusions, limitations, and applicable state mandates.”

We have found that the best way for a subscriber to receive the maximum reimbursement, is for the subscriber to confirm their insurance coverage for medical care and their financial responsibilty for their particular plan. We encourage the patient/subscriber to call their insurer to confirm coverages and reinbursements (use the 800 number on the back of card) for Psychological and/or Neuropsychological Services, CPT Codes:

90791: Diagnostic Evaluation

90834: Psychotherapy

96116: Neurobehavioral status exam

96118: Neuropsychological Testing.

We will bill the patient directly as outlined in Insurance Coverage Payments, Direct Patient Billing & Deposits.

If you have any questions regarding the necessary forms or payment policy, please feel free to contact our office at 949.478.4503 or email jdavis@npsyp.com

 

 

Insurance Coverage Payments, Direct Patient Billing and Deposits.

Due to the limited availability of service hours, we request a $295.00 deposit for the initial diagnostic appointment (96116).

48 hour notice is required for appointmnet cancellations.

Payments & Costs to the Patient

The costs of our service will depend on the type and complexity of service. Our charges are consistent with the average of major insurance carrier's PPO reimbursements.

As a courtesy, we will submit a claim to the insurance carrier. Since some of our services are not covered by some insurance carriers, as a courtesy to insurance patients, we will discuss with you payment options.

Once service begins

Before beginning Testing Cases we request an additional $600 deposit.

Proposed Treatment & Financial Policy Example

Written Reports require an additional $500 deposit and charge and will be completed and delivered to the patient upon payment of all charges due.

Upon completion and payment for services, any remaining deposit balance will be refunded promptly.

As a patient convenience, we accept credit cards, personal checks and cash for deposits and services.

 

 

 

Testing Services with Written Report

Full payment for services, including report production, must be received before a comprehensive written report is provided.

Hearings or Testimony Participation

A full retainer must be received prior to the scheduling of any hearings or procedures requiring attendance and/or testimony, including preparation time and records review.

Deposits are due before the initial appointment and before the initiation of testing.

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