Intake Form

Mind-Body Care, Inc (MBC)
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 nuances 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.
● Please note – either the insurance or client has to pay for services received at MBC.
● You must notify and keep MBC informed of your current insurance coverage or change in insurance coverage or primary and secondary insurance (if any).
● 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. Every insurance has a timely filing requirement, which is the timeframe that a claim for a service must be submitted within, starting from when the service is provided, for the claim to be considered for processing and paid for by the insurance. If you fail to provide us with the correct insurance information in a timely manner, causing us to be unable to submit claims to your insurance within the timely filing period, you will be responsible for the full 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 the full session fee.

Primary and Secondary Insurance: If you have primary and secondary insurances, you will have to let the practice know which is your primary insurance and which is secondary and to which insurance the claims need to be submitted. Otherwise, the practice can choose to submit the claim to either insurance. If the claims are denied, we will let you know so you can work with your insurance to get the claims processed. In this case, we will charge you the full fee and provide you with a receipt that you can submit to your insurance for reimbursement. If your insurance ends up paying us for these sessions, you will be issued a refund, if applicable.

Change in Insurance Coverage: If your insurance changes, it is the 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 legal contract agreement with your insurance plan. These are non-negotiable.

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.

Session 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. 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 – the 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 limit to the number of approved sessions. Check to be sure your authorization 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 expires, and you continue to receive services at our practice, you will be charged the clinician’s full private pay fee for the
sessions provided after your authorization has expired.

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.

Couples therapy: Please note that MBC does not accept all insurances for couples therapy as couples therapy services are not covered by all insurances. There is no valid procedure code for couples therapy so couples therapy sessions are private pay. Depending on the provider, we charge from $200 to $300/each 50-minute session.

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 client. Full clinician fee will be charged and is due at the time of service unless you make other/prior 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 to your insurance which MBC is not made aware of, we will be unable to submit claims to the correct insurance, resulting in claims not being processed, or insurance not paying for your session. It is your responsibility to ensure that we have your correct information and an up-to-date copy of your insurance, so that we can file claims to your insurance within the timely filing period. Please be aware that the balance of your claim is always your responsibility whether or not your insurance company pays for your claim. Your insurance benefit is a contract between you and your insurance company; MBC is not a party to that contract. MBC must receive payment for the services it provides, either from the client or their insurance.

Discounts/Waiving Client Responsibility: At MBC we aim to make mental health services affordable and accessible, and set our rates accordingly. As such, MBC does not provide any discounts, or waive any client responsibility as determined by your 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 services, called Ivy Pay and Theranest, to store credit card information securely on file. We do not provide services without an active card on file. We do not accept any other form of payment, such as 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 balances 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 there is an insurance coverage issue, and if you do not want disruption of services, you can pay full session fee until the insurance issue is resolved at which time we will refund the out-of-pocket fee charged.

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 the session fee at the time of the service.

Calls to Insurances: Once we begin treatment, it is the client’s responsibility to communicate with their insurance company to get authorizations or re-authorizations, and/or to get the answers to any questions or concerns you may have about your plan, coverage, benefits and/or payments. If you want us to assist you with these calls, and/or make any calls on your behalf, this will be an out-of-pocket expense charged at a $200/hour prorated basis, in 15-minute increments.

Commonly used CPT codes: The types of services covered by your insurance, and the fees for these services, are specific to your insurance company and insurance policy. Therefore it is not possible for us to determine how much your session fee would be for psychotherapy or psychological assessment sessions. If you want to ask your insurance about your session fee/coinsurance/copay/deductible, we use the following CPT codes:

Commonly used psychotherapy CPT 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.

Commonly used psychological assessment CPT codes
● 90791 (first intake session)
● 96132 & 96133
● 96136 & 96137
● 96130 & 96131