This policy explains how the office may use and disclose information about patients; it also informs patients of their rights as a patient/guardian. Respecting a patient’s confidential and private medical/psychiatric information is very important in this office. We work very hard to protect privacy and preserve the confidentiality of patient personal health information. Federal rules and regulations are in place to help maintain the privacy of the medical/psychiatric record. The law requires the office to give patients this written notice, follow the terms of this notice, keep medical/psychiatric information private, and only disclose patient information as is authorized or allowed by federal laws, rules, or regulations.
EXAMPLES OF USES OF HEALTH INFORMATION FOR TREATMENT PURPOSES ARE:
EXAMPLES OF USES OF HEALTH INFORMATION FOR PAYMENT PURPOSES:
EXAMPLES OF USES OF HEALTH INFORMATION FOR HEALTH CARE OPERATIONS:
INDIVIDUAL, PATIENT/GUARDIAN, HEALTH INFORMATION RIGHTS:
OUR OFFICE RESPONSIBILITIES AND RIGHTS
TO REQUEST INFORMATION OR FILE A COMPLAINT
THE FOLLOWING IS A LIST OF OTHER RIGHTS ALLOWED BY FEDERAL LAW:
NOTIFICATION – PATIENTS HAVE THE OPPORTUNITY TO AGREE OR OBJECT –
COMMUNICATION WITH FAMILY
DISASTER RELIEF EFFORTS
OPPORTUNITY TO AGREE OR OBJECT IS NOT REQUIRED BY FEDERAL LAW FOR THE CONTROLLING DISEASES
CHILD ABUSE & NEGLECT
FOOD AND DRUG ADMINISTRATION (FDA)
VICTIMS OF ABUSE, NEGLECT, OR DOMESTIC VIOLENCE
CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS
ORGAN PROCUREMENT ORGANIZATIONS
THREAT TO HEALTH AND SAFETY
FOR SPECIALIZED GOVERNMENTAL FUNCTIONS
OTHER USES AND DISCLOSURES
Policies are subject to change, please contact our office for the most updated policy.
This policy is valid for Nashville Center for Hope & Healing.
1. New Patient application: Payment for initial appointment is expected at the time of application; payment will be processed if new appointment is scheduled.
2. Hours: Regular office hours are 8:30 am to 4:00 pm Monday – Friday. Extended hours are available by appointment or direct coordination with the clinician.
3. Cancellation Policy: We have a 120-hour (Five business-day) cancellation policy for initial TEAM Evaluation or One Time Consultation, and a 72-hour (three business-day) cancellation policy for any other appointments. If you do not show or do not cancel within the notice period, you will be obligated to pay the full fee of the service. Notification must be received by 4:00pm to be counted on that business day. Cancellation fee is NOT billable to insurance.
4. Telephone Calls: NCHH office staff employees typically answer telephones 9am to 4pm. If we are assisting other patients OR if you are calling after hours, your call will go directly to voicemail. We check and respond to voice mails regularly during office hours. If you need to speak with a clinician urgently or emergently during or after office hours, you will be billed accordingly, (see “Notice of Common Non-Session Charges''). If considered medically appropriate by the clinician, calls can be scheduled with clinicians and will be billed at their prorated hourly rate. If you need administrative assistance with regards to billing, then contact the billing staff directly.
5. Use of Video Chat/Virtual visits for Clinical Communication: Our providers may communicate via a video chat format like Doxy.me, Zoom, Skype or Google Video. A patient, who uses this form of communication, agrees and understands that this form of communication has substantial and inherent security risks and hereby allows such communication. These video calls will be billed at the clinicians prorated hourly rate. If a patient does not approve of this form of communication, then the patient must refuse such forms of communication and give us notification as such in writing. Face-to-face visits, and direct phone calls offer the only, more secure alternative.
Virtual visits with clinician must comply with state and local laws, and with the clinician malpractice coverage. You may be required to be within TN in order to be seen by a Clinician at NCHH. In addition, your insurance coverage may not cover charges for virtual visits in the same way that they do for face-to-face visits.
6. Emergency Calls: We provide an on-call service for our current patients. Calls after hours will be managed and charged by the clinician on-call. Note: our clinicians rotate On-Call Coverage, so your primary clinician may not be the provider on-call.
7. Use of Email: If you provide us your email or originate an email to us, then you agree with the use of email with our office. Please note that your email system may be insecure and with continued emails, you are accepting the inherent privacy risks. EMAIL IS NOT FOR MEDICAL EMERGENCIES OR URGENT QUESTIONS. Please do not use email for urgent or complicated issues that should be properly addressed via a consultation or at minimum a phone call to the office staff and provider. We use email for administrative purposes, like billing, receipts, scheduling, and patient feedback. We only use email from the domain name healnashville.com. Do NOT accept any emails from other domains regarding care from our clinic. Patients, family members and clients understand that using email has some inherent security risks. If you do not want us to use email to communicate, then give our office notification in writing and do not supply your email to us. If a patient originates an email to us, then they therefore give us permission to communicate with them via email. Clinicians responding to email may charge for their time, at a prorated hourly rate.
8. Prescription & Refills: We prefer face-to-face appointments, and generally do not prescribe medication outside office visits. Medication refills will only be handled during office hours, during scheduled appointments, and only if a Patient is CURRENTLY under our care. If a Patient is prescribed medication, Patient will be given enough medication to cover Patient until Patient’s next scheduled appointment. If Patient’s appointment is rescheduled because of unforeseen circumstances, contact the office staff to arrange medication refills. The best way to get a refill, if it is approved, is to contact the office directly. Allow at least Three business days (72 hours) for refills. Please Do not wait until you are out of medicine to request a refill. Prescription Refills Outside of an office visit, if allowed, cost $30. This fee is not billable to Patient’s insurance as it is a non-covered charge.
9. Appointments/Charges: NCHH Clinicians make efforts to see patients at their scheduled time for their scheduled time. Situations arise where additional time is medically needed to address a specific need. If the appointment goes beyond the original booked time, then the Provider will bill for the additional amount of time in session.
10. Administrative Fees: Phone calls, letters, review of medical records, form completion, etc. will be billed based on the complexity of the job. Please be prepared to pay before your request. The basic fee schedule is noted in this Patient Pack and discussed in the Non-Covered Services/Charges section of Policies on Insurance & Payment.
11.Confidentiality & Privacy: Patient confidentiality will be respected at all levels of communication and is protected by the Federal and State Laws. There are, however, situations in which confidentiality may be compromised and the provider’s professional and legal duty to protect may override the dictates of confidentiality. Briefly, these situations may include a strong indication of imminent danger to self or others or indication of abuse or neglect of another. Patients under the age of 18 require consent from parents or a legal guardian to receive medical service. Please discuss your concerns about the limits of confidentiality with your clinician and read the Privacy (HIPAA) statement on our website, www.healnashville.com, or on file at the office.
12.Release of Information: Following the execution of a valid Patient Authorization Form (Release of Information), patient records, or a treatment summary will be forwarded to licensed professionals at no charge as a professional courtesy.
Requests to release records to any other entity (including attorneys, underwriting companies, etc.) will be billed at the actual cost of supplying the records, to include cost of reviewing, copying, mailing, and additional professional time. Any request for release of records must allow at least three weeks preparation time as a Summary of Care (SOC) may be prepared by the treating clinician.
It is the policy of our clinic to not release records directly to patients because medical & therapy records can include medical & psychiatric jargon and abbreviations. A patient may request a SOC of their treatments in our office. The typical charge for this copy is $50. Should the patient want to review their entire medical record, this can be done together, in person, in an office appointment; charges for the office appointment apply.
13. Billing Dispute: If a patient receives a charge which they believe to be invalid, our office will accept a written notice concerning the disputed charge. We will review the dispute with supporting evidence and respond in a timely manner.
14. Labs: When we partner with select Laboratories that provide testing and testing results. The lab will bill insurance directly. Some labs we use may not work with Medicare, Medicaid, or TennCare. If we collect the specimen for the laboratory test, our office may charge a collection fee which is payable at your next session or monthly statement, whichever comes first. This collection fee may not be covered by your insurance.
15. Minors: With all minors or wards, we must legally have at least one (1) parent present in the office during the first appointment, and subsequent appointments unless otherwise discussed with the clinician. The interview will include the parent for a portion of the time, but we will also take some time to see the patient alone. If parents are divorced, both can attend if they choose. It is expected that parents will maintain calm conversation focused on the patient. If it is a volatile situation between parents, it is better for one (1) parent to attend and the other to write a letter describing their observations and concerns for the child. If divorced parents do not communicate well, we alternatively suggest that the non-attending parent schedule a meeting with providers either in-person or by phone after the initial evaluation is complete. This encounter will be billed as either a consultation with a family member, or as a regular session depending on the length of time required and whether it is in-person or by phone. It is fine for the child to attend that meeting, or not. The results of any neuropsychiatric testing (ADHD, learning disorder, IQ…) should be brought to the session or provided prior to the session for review. We can request results if they are not available. If there is an Independent Educational Plan (IEP) in place at school, we would like a copy.
16. Ongoing Care vs One-Time Evaluation: Patients who elect to apply for a “New Patient Evaluation” with Ongoing Care, will receive a discounted fee (the one-time, $1500, evaluation fee is reduced by $805.00 to $695.00) and recognize that they must book, attend, and pay for three (3) additional follow-up visits, of at least 30 minutes each, within 90 days of the Team Evaluation. If for any reason the patient fails to book, attend, or pay charges for the three (3) follow-up visits within 90 days of the Team Evaluation, the patient hereby agrees to authorize NCHH to charge my credit card for the $1500 charge of the initial one-time consultation, or balance of $1500, less what the patient originally paid.
17. Video Surveillance of Property: NCHH monitors its building with 24 hour Video surveillance. The Medical Director, the administrator, and the property manager will have access to this video.
1-Out-of-Network Insurance: The contract with an insurance company to pay for any portion of patient medical care is between Patient and Patient’s insurance company. All NCHH services are out of network with insurance and NCHH files Patient’s claims as a courtesy. We will only file an out-of-network claim once based on the information Patient provides. Returned, denied, or rejected claims for any reason must be researched and resubmitted by the patient. NCHH cannot and does not guarantee out-of-network insurance reimbursement of any kind. If Patient provides accurate insurance information and is properly covered, NCHH will file claims OR prepare documents so Patient may self-file. Patients must follow up with their insurance to understand how claims will be reimbursed. Payment is due at the time of service, regardless of expectations that out-of-network insurance will cover claims. By reducing costs associated with billing, coding diagnosis and procedures, referrals, authorizations, payment delays, EOB reviews, claim denials, resubmissions, collection risks and other managed care costs, NCHH can focus on Patient’s care.
Out-of-network insurance reimbursement, if allowed, will be applied to future visits in the office and refunded to the patient in the event the patient is no longer using the services of this clinic. The Patient or responsible party is responsible to check with their insurance plan from time to time to ensure claims are being properly processed. Patient/responsible party will notify this office of any claims that need to be refiled for any reason. Any out-of-network claims that need to be re-filed, for any reason whatsoever, must be done by the patient.
2-Out-of-Network Authorization: Upon Patient request, NCHH will provide a list of fees and billing codes before any services are performed. A list of common fees is noted in the new patient packet and is subject to change. NCHH recommends contacting Patient’s insurance carrier to verify benefits and find out how much insurance will reimburse for out-of-network services provided by our office. It is Patient’s responsibility to obtain all referrals/authorizations required by Patient’s out-of-network insurance plan to file claims.
3-Statement of Service (SOS): Upon request, NCHH will provide a completed statement of service with all the codes necessary to file a claim with Patient’s out-of-network insurance carrier. We recommend Patient contact their insurance carrier and request instructions for filing claims. Patient may request a statement from billing by contacting our office or emailing the billing office.
4- Non-covered services/charges: As a patient, you have been informed that Patient health care benefits, insurer or administrator, or an insurance plan, may determine that some procedures and events are not covered by insurance, also called NON-COVERED SERVICES, including but not limited to: missed or cancelled appointments, Prescription Refills outside visits, phone calls, emails outside of visits, visits via telephone or electronic means, genetic testing, lab collection fees, emergent or urgent calls after hours, and paperwork outside of office visits (for example- records review, laboratory review and prior authorization paperwork). These services may be an Investigational Services, may be an Excluded service (non-covered service), may not be considered Medically Necessary or Medically appropriate by insurance, per a patient benefit plan from a specific Insurance Plan. A NON-Covered service would be excluded from coverage by Patient’s health care benefits plan. NCHH Clinicians strive for the best evidence based medical care and cannot foresee how an insurance company may decide the medical necessity of service. NCHH clinicians will inform Patients about alternative treatments that may be covered by Patient’s Insurance plan, if the ones we prescribe firstline are not available with your health plan.
Please understand that the Clinician may request that Patient’s insurance plan reconsider that determination by presenting evidence that the referenced service(s) is not an Investigational Service, is a Covered Service or that the service is considered to be Medically Necessary or Medically Appropriate. Patient also understand that Patient has the right to request reconsideration of that determination, as described in the Member grievance section of the healthcare benefits plan, either before or after receiving the service(s).
Patient has been informed what the potential costs of the referenced service(s) will be if elected to receive the service(s) (costs are listed in New Patient Packet). Patient understands that if insurance plan determines that the service(s) is an Investigational Service, is not a Covered Service or the service is not considered to be Medically Necessary or Medically Appropriate, then
Patient will be responsible to pay for all costs associated with the service(s), including, but not limited to, practitioner costs, facility costs, ancillary charges and any other related expenses. Patient acknowledges that his/her insurance plan may not pay for the service(s).
5-Payment: Patient understands and agrees that Patient is 100% responsible to pay for the full charge for these non-covered services, as published or prorated amount of provider’s time (Physician’s time $350/hour; NP’s time $200/hr). Patient approves and authorizes NCHH to charge Patient’s credit card as these (non-covered service) payments become due. Patient is aware that the initial appointment cancellation policy requires a notice five (5) business days prior to the appointment in order to avoid being charged for a scheduled service; Follow-up appointments require a notice – three (3) business days prior to the appointment in order to avoid being charged for a scheduled service.
6-Financing Options for Payment: We do not have payment plans or financing options internally.
7-Government sponsored insurance (Medicare, Medicaid, or TennCare): The Providers in our office have chosen not to enroll OR to terminate their Medicare contracts. We are not Medicare, Medicaid or TennCare Providers. All patients who have Medicare insurance policies (eligible for Medicare) must note that NCHH may not file a claim to Medicare, Medicaid, nor TennCare for reimbursement of your medical services. Government Sponsored insurance plans may require and stipulate physicians, nurse practitioners, therapists, and other clinicians to practice with specific medication formularies, and specific treatment protocols. Our office does not work with these government sponsored insurance plans. If you have these plans, you may receive care by clinicians who accept and work with your plan. It is important that you understand that these plans likely will not cover your care (visit costs) and may not cover your medications, or your diagnostic work up recommended by the clinician (tests and labs ordered).
Medicare usually requires that Opted-out providers or Non-Medicare providers enter into a private contract with patients in compliance with 42 U.S.C. §1395a; 42 C.F.R. § 405, subpart D. As we are NOT Medicare providers, have not been excluded, and have not entered into a contract with Medicare, we will not ask you to enter into a private contract. We want our Medicare beneficiaries to know that you can individually file a claim with Medicare using form 1490 S which can be obtained via the company that manages your benefits (PALMETTO in TENNESSEE). Again, we cannot file the claim for you, as we are not contracted with these companies. You may be reimbursed directly for the portion Medicare would have paid an in-network Medicare provider.
8-Insufficient Funds: Patient agrees and understands that the Not Sufficient Funds (NSF) Fee will be added to the patients account for any “bounced” check.
9-Interest Penalty on outstanding balance: Patient agrees and understands that any outstanding balance over 60 days is subject to the highest interest rate allowed by Law in the State of Tennessee.
10-Outstanding balance Payment Guarantee: While the majority of patient fees are paid for at the time of service, some charges like, emergency calls, prescription refills outside an appointment, no show charges, record reviews, letters, consultations with outside providers, bounced checks, etc., as an example, may be incurred when the patient is not available to pay. In the event the patient incurs any charge at any time, patient hereby authorizes this office to charge the credit card on file for the total amount outstanding. Patient can request that another form of payment be used for these outstanding charges. Upon request, patient can be given a completed statement of service with all the codes necessary to file a claim with your insurance carrier. We recommend you contact your insurance carrier and request instructions for filing your claims. You may request a statement from billing by faxing our office or emailing the billing office.