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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 $300.00 deposit for the initial diagnostic appointment and consultation.

48 hour notice is required for appointmnet cancellations.

Requests for Expedited or Time Definite (Deadline) Assessments will require a retainer at Forensic Rates.

Payments & Costs to the Patient

The costs of our service will depend on the type and complexity of service. Our charges for testing (CPT 96118) are consistent with the average of major insurance carrier's PPO reimbursements.

The charge for initial diagnostic interview (CPT 96116/90791) and records review (90885) is $300.00. Insurance carriers may reimburse between $69.00 and $ 125.00 for these CPT Codes. The Patient is responsible for the full $300.00 payment with the cost to the Patient $300.00 minus any reimbursement from their insurance carrier.

As a courtesy, we will submit a claim to the insurance carrier. Some of our services are not covered by some insurance carriers. The patient is reponsible for service charges not reimbursed by their insurance carrier.

Once service begins

A $750.00 deposit is required to begin the first testing module with a second $750.00 deposit required for the second testing module.

Financial Policy

The patient is responsible for all charges. Insurance reimbursements reduce the patient's cost of the assessment. Many testing charges are reimbursed by insurance carriers.

Written Reports for a 3rd party 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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