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ImportantInsuranceInformation) - Stamford Ophthalmology · 2014. 6. 5. ·...

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Page 1: ImportantInsuranceInformation) - Stamford Ophthalmology · 2014. 6. 5. · StamfordOphthalmology)Financial)Policy)! The!doctors!and!staff!of!Stamford!Ophthalmology!are!committed!to!providing!you!with!the!best!possible!care.!Your!
Page 2: ImportantInsuranceInformation) - Stamford Ophthalmology · 2014. 6. 5. · StamfordOphthalmology)Financial)Policy)! The!doctors!and!staff!of!Stamford!Ophthalmology!are!committed!to!providing!you!with!the!best!possible!care.!Your!

Important  Insurance  Information  Please  review  and  sign  below  so  we  can  process  your  claim  accurately  and  efficiently  

 Our  staff  will  be  happy  to  assist  you  in  submitting  and  processing  your  claims,  however,  it  is  ultimately  your  responsibility  to  know  what  your  own  medical  or  vision  plan  covers.  Please  check  your  policy  to  determine  your  coverage  prior  to  your  exam.    

Will  my  exam  be  covered  by  insurance?  Most  eye  exams,  whether  for  a  specific  eye  problem  or  for  general  vision  care,  will  be  covered  at  least  in  part  by  your  primary  medical  insurance.  As  with  any  medical  visit,  your  usual  copays  and  deductibles  will  apply.  Some  services,  including  refraction  and  contact  lens  exams,  may  not  be  covered.    

For  insurance  purposes,  eye  examinations  are  classified  as  either  “Medical”  or  “Routine.”  Your  medical  history,  current  symptoms,  and  examination  findings  will  determine  how  your  visit  is  coded.    

 

What  is  a  “Medical”  eye  exam?  Your  visit  will  be  coded  as  a  medical  exam  if  any  of  the  following  apply:    

• You  have  any  symptoms  related  to  the  health  of  the  eyes,  such  as  headaches,  eye  pain,  itching,  tearing,  redness,  dry  eye,  sudden  vision  changes,  double  vision,  light  sensitivity,  floaters,  etc.  

• You  have  a  known  medical  eye  condition,  such  as  cataracts,  glaucoma  or  macular  degeneration  or  you  have  a  family  history  of  glaucoma  

• You  have  a  history  of  diabetes,  high  blood  pressure,  or  certain  other  medical  diseases  • You  are  diagnosed  with  a  medical  eye  condition  during  your  exam  

 

During  a  medical  eye  examination,  the  doctor  will  evaluate  the  reason  for  your  symptoms  and  determine  if  any  treatment  or  additional  testing  is  required.  

 

What  is  a  “Routine”  eye  exam  and  will  my  insurance  cover  it?  If  none  of  the  above  apply  to  you,  this  constitutes  a  routine  “well-­‐vision”  exam.  During  a  routine  exam,  your  eyes  will  be  examined  for  any  needed  visual  correction  (glasses,  etc.)  and  screened  for  potential  indicators  of  eye  disease.      

Please  be  aware  that  many  insurance  plans  do  not  cover  “routine”  eye  exams  and  will  only  cover  your  exam  if  you  have  medical  symptoms  related  to  the  eyes  or  you  are  diagnosed  with  a  medical  eye  condition.    

Some  insurance  plans  will  cover  a  routine  exam  once  every  1  or  2  years,  depending  on  the  policy.  You  must  notify  our  staff  in  advance  of  your  exam  if  your  plan  will  cover  a  “routine”  eye  exam.  If  you  are  unsure,  we  recommend  that  you  check  with  your  insurance  company  prior  to  your  exam.  Once  we  submit  a  claim,  it  cannot  be  changed  from  medical  to  routine  or  vice  versa.    

 

Refraction:  What  is  it  and  does  my  insurance  cover  it?  Refraction  is  the  diagnostic  procedure  used  to  determine  your  best-­‐corrected  vision.  This  can  be  achieved  at  all  ages  using  different  techniques,  but  usually  involves  looking  through  a  device  with  adjustable  lenses  while  the  doctor  has  you  read  letters  on  an  eye  chart.  Refraction  must  be  performed  in  order  for  the  doctor  to  prescribe  glasses.  For  some  medical  conditions  and  for  most  children  who  have  been  referred  after  a  failed  vision  screen,  refraction  is  needed  even  if  glasses  are  not  prescribed.  Unfortunately,  the  majority  of  insurance  companies  (including  Medicare)  do  not  cover  this  essential  procedure.  If  your  insurance  does  not  cover  refraction,  you  will  be  billed  accordingly.  The  current  fee  for  refraction  is  $75  (subject  to  change)  and  is  due  on  the  day  of  service.  

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 Does  Stamford  Ophthalmology  accept  Vision  Plans?  We  do  not  participate  with  most  vision  plans;  however,  Dr.  Pribis  does  accept  EyeMed  and  Davis  Vision  for  “routine”  eye  examinations  only.  If  you  have  any  medical  symptoms  related  to  the  eyes,  or  if  the  doctor  diagnoses  any  medical  condition  during  your  exam,  your  claim  must  be  processed  through  your  regular  medical  insurance.  You  may  inquire  at  the  optical  shop  to  see  if  your  vision  plan  can  help  cover  the  cost  of  glasses.    

Will  insurance  cover  my  contact  lens  examination?  Medical  insurance  plans  do  not  consider  contact  lenses  medically  necessary  and  will  not  typically  cover  contact  lens  fittings  or  annual  contact  lens  examinations.  Please  review  our  contact  lens  agreement  for  details  regarding  our  fees  and  policies.    

What  if  I  don’t  have  any  medical  insurance?  If  you  do  not  have  any  medical  insurance,  payment  for  any  services  provided  is  expected  in  full  on  the  day  of  your  visit.  You  may  inquire  with  our  staff  regarding  approximate  fees.    -­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐-­‐    Please  check  ONE  and  sign  below:    

☐ Please  submit  my  claim  to  my  primary  medical  insurance  as  a  medical  eye  exam.  I  understand  that  my              usual  copays  and  deductibles  will  apply  and  I  will  be  responsible  for  any  uncovered  services.  

 

☐ My  medical  insurance  plan  will  cover  a  routine  well-­‐vision  eye  exam.  I  have  no  symptoms  related  to  the  health  of  my  eyes  and  no  known  medical  eye  conditions.  I  understand  that  if  I  am  diagnosed  with  a  medical  condition  during  my  exam,  or  if  any  additional  testing  is  required,  my  claim  cannot  be  considered  “routine”  and  will  instead  be  coded  as  a  medical  eye  exam.  Please  be  advised  that  this  cannot  be  changed  once  your  claim  has  been  submitted  to  your  insurance,  so  please  be  sure  of  your  coverage  prior  to  your  exam.  

☐ I  have  EyeMed  /  Davis  (circle  one)  and  would  like  Dr.  Pribis  to  perform  a  “routine”  eye  exam.  I  understand            that  if  I  am  diagnosed  with  a  medical  condition  during  my  exam,  or  if  any  additional  testing  is  required,  my  claim  must  be  processed  though  my  regular  medical  insurance.  

☐ I  do  not  have  any  medical  insurance  at  this  time.  I  understand  that  I  will  be  responsible  for  payment  in  full  on  the  day  of  service.  

   Patient  Name:  _______________________________________          Guardian  (if  patient  is  under  18):  _____________________________________    Signature:  ________________________________      Date:  ____  /____  /_____  

 

Page 4: ImportantInsuranceInformation) - Stamford Ophthalmology · 2014. 6. 5. · StamfordOphthalmology)Financial)Policy)! The!doctors!and!staff!of!Stamford!Ophthalmology!are!committed!to!providing!you!with!the!best!possible!care.!Your!

Stamford  Ophthalmology  Financial  Policy    The  doctors  and  staff  of  Stamford  Ophthalmology  are  committed  to  providing  you  with  the  best  possible  care.  Your  clear  understanding  of  our  financial  policy  is  important  to  our  professional  relationship.      • Full  payment  is  due  at  the  time  of  service  or  on  receipt  of  statement  after  insurance  payment  has  been  made  to  Stamford  Ophthalmology.  

• Insurance  co-­‐payments,  deductibles,  refraction  fees  and  fees  for  any  other  non-­‐covered  services  are  due  at  the  time  of  service.  A  $25  administrative  fee  will  be  added  for  any  applicable  payments  not  made  at  the  time  of  service.  Due  to  recent  changes  in  health  care  law,  we  are  not  permitted  to  waive  copays  or  deductibles.  

• If,  after  reasonable  attempts  are  made  at  obtaining  payment  for  outstanding  bills,  your  account  is  turned  over  to  collections,  you  will  be  responsible  for  an  additional  30%  finance  charge.  

 Forms  of  payment  accepted:    Cash,  Check,  Visa,  MasterCard,  American  Express  and  Discover.  There  is  a  $35  charge  for  returned  checks.    Cancellation  policy  /  Missed  Appointments:  Please  note  that  failure  to  provide  24  hours  notice  of  appointment  cancellation  may  result  in  a  $50  cancellation  fee.    Unaccompanied  Minors:  Minors  under  the  age  of  18  must  be  accompanied  by  a  parent  or  authorized  guardian.      Regarding  insurance:  • If  you  have  insurance,  we  will  help  you  receive  maximum  benefits.  • If  you  have  an  indemnity  plan  or  if  we  do  not  participate  with  your  insurance,  we  will  be  happy  to  provide  you  with  a  copy  of  your  receipt  so  that  you  can  be  reimbursed  by  your  insurance  company.  

• Insurance  is  a  contract  between  you  and  your  insurance  carrier.  We  are  typically  not  party  to  this  contract.  If  we  are,  we  will  inform  you  and  handle  the  claim  according  to  our  agreement  with  the  insurance  company.  We  file  insurance  claims  as  a  courtesy  to  our  patients  and  will  not  become  involved  in  disputes  between  you  and  your  carrier  regarding  deductibles,  co-­‐payments,  covered  charges,  and  secondary  insurance  or  other  matters  regarding  reimbursement.  We  do  not  routinely  file  secondary  insurance  claims,  however,  we  will  provide  a  receipt  so  that  you  can  be  reimbursed.  

• There  has  been  a  continual  increase  in  private  insurance  companies  requiring  pre-­‐admission  certification  for  outpatient  procedures  and  some  office  visits.  It  is  your  responsibility  to  be  aware  of  the  requirements  of  your  insurance  policy  and  alert  us  prior  to  any  outpatient  procedures.  Failure  to  do  so  may  result  in  partial  or  complete  denial  of  benefits  if  your  insurance  policy  subsequently  determines  the  services  not  to  be  payable.  

• You  are  responsible  for  the  timely  payment  of  your  account    Medicare  /  Medicaid  /  Workman’s  Compensation:    If  you  are  covered  by  Medicare,  Medicaid,  Workman’s  Compensation,  or  any  other  government  sponsored  program,  please  discuss  your  payment  situation  with  our  office  staff  prior  to  the  date  of  service.    Thank  you  for  taking  the  time  to  understand  our  financial  policy.  Please  inquire  with  our  office  staff  if  you  have  any  questions  or  concerns  regarding  our  professional  fees  or  financial  policies.    I  understand  and  agree  to  the  above  financial  policy  of  Stamford  Ophthalmology.  I  understand  that  my  signature  requests  that  payment  be  made  to  Stamford  Ophthalmology  and  authorizes  the  release  of  medical  information  necessary  to  pay  the  claim  with  the  approved  claim  forms  or  electronically  submitted  claims.  My  signature  authorizes  the  release  of  the  information  to  the  company  shown  in  my  file.      Name:  _______________________________    Signature:  ______________________________    Date:  ____________  

Page 5: ImportantInsuranceInformation) - Stamford Ophthalmology · 2014. 6. 5. · StamfordOphthalmology)Financial)Policy)! The!doctors!and!staff!of!Stamford!Ophthalmology!are!committed!to!providing!you!with!the!best!possible!care.!Your!

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