1-GENERAL IN-NETWORK INSURANCE:
The contract with an insurance company to pay for any portion of patient medical care is between the patient and the patient insurance company. NeuroScience & TMS Treatment Centers (NS-TMS) clinicians are in-network with SOME insurance and NS-TMS files Patient’s claims for in- network insurance only. If Patient provides accurate insurance information and is properly covered, NS-TMS will file in-network claims and follow up on reimbursement. If we are in-network with an insurance company and are contractually required to obtain authorization for care, we will complete this process.
A patient must certify that he/she (or Patient’s dependent) has insurance coverage, and If any NS-TMS clinician seen is a contracted provider with Patient’s insurance, Patient assigns directly to NS-TMS all insurance benefits. NS-TMS will file these in-network insurance claims and it is the Patient obligation to pay the copay, deductible, and any co-insurance due. If Patient’s insurance company fails to reimburse because of non-coverage, Patient is still financially responsible for all charges. Patient, hereby, authorizes NS-TMS to release all information necessary to secure the payment of benefits. Patient authorizes the use of this signature on all insurance submissions.
2- OUT OF NETWORK INSURANCE: Payment is due at the time of service, regardless of expectations that out-of-network insurance will cover claims. By reducing costs associated with billing, coding diagnosis and procedures, referrals, authorizations, payment delays, EOB reviews, claim denials, resubmissions, collection risks and other managed care costs, we can focus on Patient’s care. Reimbursement, if allowed, will be paid to the patient as is allowed by your insurance. If you are out-of-network, you will be expected to pay in full for your appointments and services rendered in the clinic. NS-TMS cannot and does not guarantee out-of-network insurance reimbursement of any kind. We can provide a statement of service (SOS) to the patient or parent/guardian for reimbursement out of network, but you will have to submit this form to your insurance company. We recommend Patient contact their insurance carrier and request instructions for filing claims. Patients must follow up with their insurance to understand how claims will be reimbursed. The Patient or responsible party is responsible to check with their insurance plan from time to time to ensure claims are being properly processed.
3- OUT-OF-NETWORK AUTHORIZATIONS: Upon Patient request, we will provide a list of fees and billing codes before any services are performed. A current list of fees is attached and is subject to change. We recommend contacting the Patient’s insurance carrier to verify benefits and to find out how much insurance will reimburse for services provided by our office. It is Patient’s responsibility to obtain all referrals/authorizations required by Patient’s out of network insurance plan to file claims.
4-NON-COVERED SERVICES/CHARGES: Patient has been informed that Patient’s healthcare benefits insurer or administrator, insurance plan, may determine that some procedures and events are not covered by insurance, also called NON-COVERED SERVICES, including but not limited to: missed or cancelled appointments, Prescription Refills outside visits, phone calls, emails outside of visits, visits via telephone or electronic means, genetic testing, lab collection fees, emergent or urgent calls after hours, and paperwork outside of office visits (for example- records review, laboratory review and prior authorization paperwork). These services may be an Investigational Services, may be an Excluded service (non-covered service), may not be considered Medically Necessary or Medically appropriate by insurance, per a patient benefit plan from a specific Insurance Plan. A NON-Covered service would be excluded from coverage by Patient’s health care benefits plan. NS-TMS Clinicians strive for the best evidence based medical care and cannot foresee how an insurance company may decide the medical necessity of service. NS-TMS clinicians will inform Patients about alternative treatments that maybe covered by Patient’s Insurance plan, if the ones we prescribe first line are not available with your health plan.
Patient understands that the Provider may request that Patient’s insurance plan reconsider that determination by presenting evidence that the referenced service(s) is not an Investigational Service, is a Covered Service or that the service is considered to be Medically Necessary or Medically Appropriate. Patient also understand that Patient has the right to request reconsideration of that determination, as described in the Member grievance section of health care benefits plan, either before or after receiving the service(s).
Patient has been informed what the potential costs of the referenced service(s) will be if elected to receive the service(s) (costs are listed in New Patient Packet and on the website). Patient understands that if insurance plan determines that the service(s) is an Investigational Service, is not a Covered Service or the service is not considered to be Medically Necessary or Medically Appropriate, then Patient will be responsible to pay for all costs associated with the service(s), including, but not limited to, practitioner costs, facility costs, ancillary charges and any other related expenses. Patient acknowledges that his/her insurance plan may not pay for the service(s).
5-PAYMENT OF NON-COVERED CHARGES: Patient understands and agrees that Patient is 100% responsible to pay for the full charge for non-covered services, as published or prorated amount of provider’s time (Physician’s time $350/hour, NP’s time $200/hour). Patient approves and authorizes NS-TMS to charge Patient’s credit card as these (non-covered service) payments, become due. Patient is aware that the initial and follow-up appointments cancellation policy requires a notice three (3) business days prior to the appointment in order to avoid being charged for a scheduled service.
6-FINANCING OPTIONS FOR PAYMENT: We do not have payment plans or financing options internally. We recommend using a credit card to finance your payments with us if you prefer.
7-GOVERNMENT SPONSORED INSURANCE (MEDICARE, MEDICAID, OR TENNCARE): The Providers at NS-TMS have chosen not to enroll OR have chosen to terminate their Medicare contracts. We are not Medicare, Medicaid or TennCare Providers. All patients who have Medicare insurance policies (eligible for Medicare) must note that NS-TMS may not file a claim to Medicare, Medicaid, nor TennCare for reimbursement of your medical services. Government Sponsored insurance plans may require and stipulate physicians, nurse practitioners, therapists, and other clinicians to practice with specific medication formularies, and specific treatment protocols. Our office does not work with these government sponsored insurance plans. If you have these plans, you may receive care by clinicians who accept and work with your plan. It is important that you understand that these plans likely will not cover your care (visit costs) and may not cover your medications, or your diagnostic work up recommended by the clinician (tests and labs ordered).
Medicare usually requires that Opted-out providers or Non-Medicare providers enter into a private contract with patients in compliance with 42 U.S.C. §1395a; 42 C.F.R. § 405, subpart D. As we are NOT Medicare providers, have not been excluded, and have not entered into a contract with Medicare, we will not ask you to enter into a private contract. We want our Medicare beneficiaries to know that you can individually file a claim with Medicare using form 1490 S which can be obtained via the company that manages your benefits (PALMETTO in TN). Again, we cannot file the claim for you, as we are not contracted with these companies. You may be reimbursed directly for the portion Medicare would have paid an in-network Medicare provider.
8-INSUFFICIENT FUNDS: Patient agrees and understands that the Not Sufficient Funds (NSF) Fee will be added to the patients account for any “bounced” check.
9-INTEREST PENALTY ON OUTSTANDING BALANCE: Patient agrees and understands that any outstanding balance over 60 days is subject to the highest interest rate allowed by Law in the State of Tennessee.
10-OUTSTANDING BALANCE PAYMENT GUARANTEE: While the majority of patient fees are paid for at the time of service, some charges like, emergency calls, prescription refills outside an appointment, no show charges, record reviews, letters, consultations with outside providers, bounced checks, etc., as an example, may be incurred when the patient is not available to pay. In the event the patient incurs any charge at any time, patient hereby authorizes this office to charge the credit card on file for the total amount outstanding. Patient can request that another form of payment be used for these outstanding charges. Upon request, patient can be given a completed statement of service with all the codes necessary to file a claim with your insurance carrier. We recommend you contact your insurance carrier and request instructions for filing your claims. You may request a statement from billing by faxing our office or contacting our billing office.