Intake Form

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.

Please note -MBC is an outpatient mental health practice, not an insurance provider. We accept insurance plans to support client access to care but have no control over how insurances process claims.

● Knowing your insurance benefits is your responsibility.
● Knowing that your insurance covers mental health services is your responsibility. Often times, this information is not available to the provider’s office.
● Please note – either the insurance or the client has to pay for the 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 credit card on file.

Insurance Verification: While we make every effort to verify your insurance eligibility and benefits online before your first appointment, it is essential that you also confirm your coverage directly with your insurance plan prior to starting services. Please note that the benefits we obtain from online systems are not always accurate and may differ from how your insurance ultimately processes your claims.

Because of this, the estimated client responsibility we share with you at the start of treatment may change once claims are processed. Any client responsibility determined by your insurance will be charged to the credit card on file.

If you are not covered by an insurance plan that we are contracted with, full payment is required at the time of each visit. Similarly, if you are insured by a contracted plan but we do not have your active insurance information on file, full payment is required until your coverage can be verified.

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, and the claim is not submitted in a timely manner to your insurance (as required by insurances), you will 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.

Primary and Secondary Insurance: If you have primary and secondary insurance, 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 full fee, provide you with a receipt/superbill that you can submit to your insurance for reimbursement. If 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 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 session fee will automatically be billed to you and charged to your credit card on file. This will be refunded if your insurance company ends up paying for the sessions.

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 and will not be waived.

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 you would have to pay towards deductibles.

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 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.

Couples Therapy: Please note that MBC does not accept all insurances for couples therapy as couples therapy services are not covered by all the 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 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 filing limit for claims, meaning the claims must be submitted within a certain timeframe for them to be considered for processing and being paid by the insurance. The balance of your claim is your responsibility. 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 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 client portal Theranest to store credit card securely on file. We do not provide services without an active credit 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 balances and give you the opportunity to clear the previous balance. The services will resume once the previous balance is cleared, and an active credit 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 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 15 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 outof-pocket expense charged at $200/hour prorated basis, in 15-minute increments.

Commonly used CPT codes: Different insurances pay different rates and cover different types of services. If you want to know your session fee/coinsurance/copay/deductible, we use the following CPT codes for psychotherapy:

● 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.

The following CPT codes are used for psychological assessments:
90791, 96130, 96131, 96132, 96133, 96136 and 96137.