INTAKE FORM

Mind-Body Care, Inc
Insurance and Financial Policies

Thank you for choosing MBC for your health care needs. Today's reimbursement climate is in a constant state of flux. Unfortunately, it is not possible for our billing department to understand the full details and insurances of each individual's psychotherapy and psychological assessment coverage, as the insurance company always gives the disclaimer that the information they give us is subject to the processing under the plan umbrella, and will be subject to those terms at the time of processing (basically informing us misinformation is possible, and they are not liable for it). To assist you in fully understanding your psychotherapy and psychological assessment coverage under your insurance plan, we have developed this document.

• Knowing your insurance benefits is your responsibility.
• You must notify and keep MBC informed of your current insurance coverage.
• MBC will submit claims to the insurance details you provided, but that is not a guarantee of payment.
• You will be charged for any remaining balance your insurance does not cover. Since we get your credit card authorization, we will inform you of client responsibility and charge to the card on file.
• Payment is expected at time of service.
• Any remaining balance not paid within 30 days of the billing invoice, MBC reserves the right to add late fees, send to collections, file a legal claim, and/or discharge you from service.
• MBC has a 48-hour no-show or late cancellation policy, and clients are charged their therapist’s
full fee for late cancellations or no shows, charged to the card on file.

Insurance Verification: Though we try to verify your eligibility and benefits (online) before your first appointment, it is of critical importance for you to know of your benefits prior to your first appointment. If you are not insured by a plan, we do business with, full payment is expected at each visit. If you are insured by a plan, we do business with, but don’t have active insurance on file with us, full payment for each visit is required until we can verify your coverage.

Proof of Insurance: All clients must complete our client registration form before seeing a healthcare provider. It is your responsibility to ensure that we have your correct information and an up-to-date copy of your insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. You are also responsible to know if your mental health benefits are carved out to another company or if you also have secondary insurance. Failure to provide MBC all the insurance details may lead to your services not covered. In these cases, you will be responsible for full session fee.

Change in Insurance Coverage: If your insurance changes, it is client’s responsibility to notify us before your next visit so that we can make the appropriate changes to help you receive your maximum benefits.

Insurance payments: You will be responsible for any copays, co-insurances, deductibles, and any other client responsibility determined by your insurance. This balance will automatically be billed to you and charged to your card on file. If your insurance company does not pay your claim in 60 days, the balance will automatically be billed to you.

Co-Payments, Deductibles & Coinsurance: All co-payments, deductibles & coinsurance must be paid at the time of service or as soon as you are informed. Payment of your co-payments, deductibles & coinsurance is part of your contract agreement with your insurance plan.

Your deductible must be satisfied before the insurance company will pay for treatment. You will be billed for any unsatisfied deductible amount. Please call your insurance to know if you have met your deductibles or not and how much would you have to pay towards deductible.

Office co-pays are due at the time of service. The co-pay amount on your insurance card or online may not be the co-pay amount for psychotherapy visits. You must obtain this information from your insurance customer service representative. We will bill copayments to the credit card on file. We will let you know of your copayment based on what we find out upon checking your eligibility and benefits online but this is subject to change after your first claim is processed. We will notify you of any such change.

Your co-insurance amount is the amount not covered by your insurance plan. The co-insurance amount is a patient's responsibility. You will be billed for your co-insurance amount on a weekly basis - same as we bill copays.

Authorizations: If your policy requires a referral or pre-authorization on file, you will need to contact your PCP’s referral coordinator or your insurance and ask that a current copy of the authorization be sent to our office. We will need this before we begin working with you. Our confidential office fax is 408-905-4918. Obtaining a prior authorization for mental health services is not a guarantee of payment of benefits by the insurance.

Be aware that pre-authorizations have expiration dates and/or a set visit limit. Check to be sure your paperwork has not expired prior to your first visit. We can assist you in tracking expirations of pre-authorizations once you have begun care with us, but we also suggest that you keep track of your authorization expiration. You will be responsible to get re-authorization for continuity of care. If your authorization on file expired, and you continued to receive services at our practice, you will be charged clinician’s full private pay fee for the sessions with expired authorization.

Non-Covered Services: Please be aware that some or perhaps all the services you receive at MBC may not be covered or considered reasonable or necessary by your insurance plan. If you elect to have these services with us, you will be responsible for paying for these services in full at the time of the visit.

Self-Pay: If you do not have valid health care coverage or your insurance does not cover your sessions, you will be considered as self-pay. Full clinician fee will be charged and is due at the time of service unless you make other arrangements with our finance department.

Claims Submission: We submit claims within a week of your session. We will keep you informed if for some reason, your insurance does not pay for your session or denies your claim so you can follow up directly with your insurance. If there is any change in your insurance which MBC is not made aware of, we will submit claims to the insurance details you provided, resulting in claim not processed or insurance not paying for your session. Every insurance has timely filed limit, meaning the claims must be submitted within a certain timeframe for them to be considered for processing and being paid by the insurance. Please be aware that the balance of your claim is your responsibility whether your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; MBC is not a party to that contract.

Discounts/Waiving Client Responsibility: Since MBC takes insurances making mental health services affordable and accessible, MBC does not give any discounts or waives any client responsibility as determined by our insurance. Our failure to collect payment may be a violation of billing compliance and may be considered as an act of fraud by your insurance plan.

Payment Methods: We use HIPAA compliant app called Ivy Pay to keep credit card on file. We do not provide services without an active card on file. We do not accept cash, personal checks, money orders, cashier’s checks, Venmo, Zelle, etc. If the card on file declines when we attempt to charge client responsibility, we will pause the sessions temporarily to avoid accumulation of large balance and give you the opportunity to clear the previous balance. The services will resume once the previous balance is cleared, and an active card is on file.

If payment for services provided is not made within thirty (30) days after receiving a billing statement, there will be a $50.00 late fee added to the amount due. There will continue to be a $50.00 charge for each additional thirty (30) days that payment is not received and our policy around non-payment/delinquent balances will be enforced. If your account is over 60 days past due, you will receive a statement indicating that you have 30 days to pay your account in full. Partial payments will not be accepted unless you have contacted our office and arranged otherwise.

Please be aware that if a balance remains unpaid, we will turn your account over to a collection agency or file a legal claim and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified that you have 30 days to find alternative medical care. During that 30-day period, our clinician will only be able to meet you for any crisis sessions and you will be responsible for session fee at the time of the service.

Calls to Insurances: Once we begin treatment, we WILL NOT make any calls on your behalf to your insurance to get authorizations or re-authorizations, or any questions you may have about your benefits and/or payments. If you want us to assist you with these calls, this will be an out-of-pocket expense charged at $200/hour prorated basis, in 15-minute increments.

Commonly used CPT codes: It is not possible for us to determine how much session fee would be for psychotherapy or psychological assessment sessions. Different insurances pay different rates and cover different types of services. If you want to know your session fee/co-insurance/co-pay/deductible, we use the following CPT codes:

Psychotherapy Codes
• 90791 (first intake session)
• 90837 (psychotherapy session 55 mins)
• 90834 (psychotherapy session 45 mins)
• 90832 (psychotherapy session 30 mins)
• 90847 (family therapy session)
• 90839 and 90840 (crisis session)
• additional CPT codes based on services provided.

Psychological Assessment codes
• 90791 (first intake session)
• 96132 (30-minute code for test administration)
• 96136 (60-minute code for test scoring, interpretation, report writing, feedback session)
• 96130 (60-minute code for test scoring, interpretation, report writing, feedback session)
• additional CPT codes based on services provided.