Authorization to bill insurance: As a courtesy, our office will bill in-network insurance companies one time. We are contracted by several medical insurance plans. Prior to scheduled appointments, we will verify eligibility and benefits. As of 01.01.2024, if we are unable to verify insurance eligibility one business day prior to your appointment, you will be charged for the self-pay rate for your appointment.
Self-pay rates: Initial evaluation: $275 (60 minutes) Extended medication management: $250 (60 minutes) Medication management (uncomplicated): $150 (30 minutes). Charges will be run on the card you have on file. If the charge is declined, an alternate card must be provided for payment at least one hour prior to the appointment time or your appointment will be cancelled. If alternate payment information hasn’t been obtained at least one hour prior to your appointment time, you may be assessed a missed appointment fee of $150 which must be paid in full prior to rescheduling.
Our billing department will bill your primary insurance carrier once. We no longer bill secondary insurance carriers. If the claim is rejected, you will be provided with a super bill, and you may seek reimbursement from your insurance carrier. You will be responsible for all claims unpaid or denied by your insurance carrier. Patients who do not supply accurate insurance information will be responsible for balance in full. You must inform our office of any changes in your insurance prior to your appointment, as you are the policyholder, and it is your responsibility. We will no longer retroactively bill insurance. It will be your responsibility to pay for all charges incurred. We will provide a superbill, which you may submit to seek reimbursement from your insurance carrier. Additionally, if your insurance company does not respond to claims within 60 days of submission, the cost of your appointment becomes your financial responsibility, at the contracted rate established with your insurance company. Insurance Referrals: If your plan requires a referral from your Primary Care provider, it is your responsibility to obtain it before seeking treatment from us. If a claim is denied due to a lack of referral you will be responsible for charges. You understand that you are financially responsible for claims denied or not covered by your insurance carrier for failure to obtain a referral.
By signing this consent, you authorize release of information, including treatment and protected health information to your insurance company that is needed to process payment for services. You authorize your insurance carrier to pay benefits for services rendered, directly to Indy Behavioral Health or any of its affiliates. By signing this consent, you acknowledge that you have read and agree to the terms of the above information, payment is expected at the time services are rendered, and that you are responsible for any balance. Please realize that you have the ultimate responsibility of verifying the coverage with your insurance. You acknowledge that we may be an out of network provider with your insurance. We do not bill out of network carriers. You are also aware that in some circumstances your insurer will send payment directly to you. If this occurs, you agree to endorse the insurance check and forward funds to the appropriate entity above within 30 days of receipt.
Office Appointments, Fees, Forms, And Cancellation Policies: PLEASE NOTE THAT APPOINTMENTS MAY NEED TO BE RESCHEDULED WITHOUT NOTICE DUE TO EMERGENCY SITUATIONS. Our office tries to meet the needs of all of our patients but in particular our patients in crises that need our urgent attention. To open appointment slots for patients in crises, the following scheduling policies have been implemented: To schedule an appointment, please call our office at 317-978-0257. Prior to the appointment, you will receive an automated reminder. Please be aware, though, that this reminder service is a courtesy to our patients and that they are ultimately responsible for charges incurred due to a missed appointment. We understand that there may be circumstances that are beyond your control, and we will try to accommodate them as best we can. However, there is a 24-hour cancellation policy. As of 01.01.2024, we will no longer be able to make exceptions to this policy. You may cancel or reschedule your appointment anytime 24 hours before your appointment. If the appointment is cancelled less than the 24-hour period or missed completely without notification the following consequences apply: Cancellations: We ask that you provide 24-hour notice for appointments that must be cancelled and or rescheduled. Less than 24-hour notice and/or not showing for an appointment (no-shows) will result in a missed appointment fee of $150.00, which MUST be paid prior to rescheduling. Appointments must be cancelled by calling the front office at 317-978-0257 or by online patient portal. Three no-shows within a rolling 12-month period may result in dismissal from the practice. In addition, if an appointment is cancelled and is not rescheduled within a 45-day period, we will conclude that you no longer require our services and reserve the right to close your file.
PAYMENT: Payment is to be paid in full at the time of appointment. Accepted forms of payment include credit or debit cards, which must be kept on file. If for some reason your balance is not paid in full within 45 days, we reserve the right to turn your account over to collections. We do not participate in Medicaid (including Hoosier Healthwise and Healthy Indiana Plans). Please contact your health insurance carrier about your mental health benefits.
CARD ON FILE POLICY: Indy Behavioral Health requires all patients, with the exception of veterans whose health care is covered by the VA, to provide a credit, debit or health care savings card to be kept on file. By accepting these terms and conditions I authorize Indy Behavioral Health to charge the credit/debit card saved to my profile for all outstanding balances, including but not limited to copayment and coinsurance amounts, self-pay fee schedule amounts, no-show/cancellation fees, administrative fees, fees associated with completion of forms and reports (including but not limited to short term disability and FMLA) and any balance remaining after insurance reimbursement relating to services provided to the patient. I understand that it is my responsibility to ensure that the information for the card on file is current at the time of service. I also understand that if a payment is declined the day of my appointment, it will be cancelled and I will be assessed a cancellation fee of $150, which must be paid in full prior to rescheduling. Indy Behavioral Health is not responsible for any overdraft fees should a payment exceed the amount in the account associated with the card on file. I certify that I am an authorized signer for the card on file with all necessary rights to authorize the charges.
STANDARD FEE SCHEDULE: Thank you for choosing our office for your mental health needs. We strive to provide a warm and compassionate environment while addressing the presenting psychiatric issues with the utmost level of professionalism and sensitivity. Effective January 1, 2024, Self-pay rates (without insurance) are as follows: 1. INITIAL EVALUATION: $275 (60 minutes) 2. EXTENDED MEDICATION MANAGEMENT $225 (60 minutes) 3. MEDICATION MANAGEMENT (uncomplicated) $150 (30 minutes).
FORMS: Patients are sent several forms via the patient portal seven days prior to scheduled appointments and must be completed prior to each appointment. Please be advised that your provider WILL NOT join virtual appointments unless all forms are completed. If your provider is unable to join the appointment due to incomplete forms, your appointment will be cancelled and you will be assessed a missed appointment fee, which must be paid in full prior to rescheduling.
WRITTEN REPORTS: Occasionally, requests are received for reports, treatment reports for insurance companies, and written evaluations to be sent to individuals or agencies. You will be billed for the time required to complete such reports, as well as clerical costs as follows: Pages 1-10 $1.00 per page, pages 11-50 $.50 per page, pages 51+ $.25 per page. Expedited copy fee: $10.00, Certified Records fee: $20.00. Payment in full must be made prior to our office submitting these types of forms. FMLA or Short-Term Disability Forms: For us to thoroughly assess the extent of your symptoms, you must be seen on at least four occasions before we will consider completing FMLA or short-term disability paperwork. Completion of these forms is at the provider’s discretion and is based on our assessment of functional impairment. The cost for initial or updated FMLA/disability paperwork is calculated on the provider’s hourly rate. To request completion of forms, please go to our website: www.indybehavioralhealth.com, select “forms,” then “Provider Letter and Form Completion Request.”