Fee Schedule for Uncovered Medical
Services
NC Pain Management Services, PA is dedicated to serving our
patients with the highest quality of care at the lowest possible cost. We ask
that you help keep our fees at a competitive level by observing the following
financial policy. The purpose of this
statement is to help you understand our policy in relation to Pain Clinic
charges. We encourage open discussion of services and fees prior to treatment.
It is your ultimate responsibility to see that all charges are paid.
The following fee schedule will apply to those services not
covered by the clientís medical insurance. In those cases where the insurance
covers for the service, they will be billed to them, as per any other covered
service. When services are not covered by the insurance carrier, the patient or
client will be responsible for payment. This financial policy information is specific for NC
Pain Management Services, PA and therefore any questions should be directed to our
physician billing service, currently ìPractice Solutions LLCî, at our
toll free number 1-800-427-7487.
Since insurance plans vary, we recommend that you be
familiar with your plan benefits as they relate to deductibles, co-pays,
non-allowed charges, and pre-certification. Your insurance coverage represents
a contract between you and your insurance carrier. If you have an insurance
policy, such as an HMO/PPO that requires pre-certification
/ pre-authorization or referrals for any service, including office visits, it
is your responsibility to obtain it, update it, and keep them current. If
you need any help, our staff will be more than happy to help you through the
process. In your insurance card there will be a telephone number, which is the
number that you should call for pre-approvals or information on deductibles,
co-pays, allowable, and pre-certification. You can also use this number to find
out what your insurance company allowable is, for the proposed treatment. If
you have any questions about the requirements of your coverage, please contact
your employer or insurance carrier. We cannot interpret policies for you.
Remember that the difference between the allowable and the cost of the
treatment will be your personal responsibility. You will be responsible for
services rendered that are outside the scope of any referral issued by your
insurance carrier. You are expected to be aware of any and all conditions of
your insurance coverage. Please provide us with information on any secondary
insurance coverage that you may have, as they may cover the difference.
Your payment
or co-pay is due at the time of your service. This may be paid in cash,
with a check, at the time of your service, or it may be paid using your credit
card, within two (2) weeks of your service. Please indicate your preference to
the receptionist, at the time of your service.
Click here for: FEE SCHEDULE
FOR DEPOSITIONS AND Other Legal Services
For
the following list, click on each item for further information and
restrictions:
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Copies
of medical records |
Service
provided by Hospital, at a cost. Call Patient Accounting Office: 336-538-8400 |
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$65.00 (per page) |
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$20.00 (Only given to patients
in wheelchairs) |
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$250.00 (per hour or fraction
there of.) |
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$20.00 (Payment should be
handed in with paperwork to be completed) |
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$63.40 (per every 15 minutes, or
fractions there of) |
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$50.00 + cost of the wasted
medication (could be up to $400.00) |
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$50.00 |
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$100.00 (without adequate
notification) |
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No-shows
to scheduled studies or referrals |
$20.00 |
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Paperwork
for patient assistance programs |
Free service provided by
Hospital |
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Phone
calls to nurses, initiated or
requested by patient |
Free service provided by
Hospital |
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$63.40 (per every 15 minutes,
or fractions there of) |
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We
can receive information, but we can not give any. Restricted by Privacy Laws. |
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Phone
consults to other physicians,
requested by patient |
$63.40 (per every 15 minutes, or
fractions there of) |
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Preauthorization |
Free service provided by
Hospital |
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$20.00 (Payment should be
handed in with paperwork to be completed) |
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Refills
or prescription changes handled outside of an office visit |
$50.00 |
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Renewal
of Prescription by phone |
No Phone refills. If done under
extraordinary circumstances - $25.00 |
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$10.00 (No charge for those
given at procedures or visits) |
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$20.00 (Payment should be
handed in with paperwork to be completed) |
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