Billing Policy
Point of Service Billing Policy
Thank you for choosing Montville Oral Surgery Associates. Our surgeons are committed to the success of your treatment and care. Payment of your bill is part of this process, and this policy explains our expectations for payment of office services.
We have a series of options for patients who need financial assistance. Please ask to speak with our Financial Counselor for details.
Accepted Forms of Payment
Our practice accepts in the form of cash, check, Visa, Mastercard, Amex and Discover.
Referral Requirements
If you have an HMO plan with which we are contracted, you need a referral authorization from your primary care physician. If we have not received an authorization prior to your arrival at the office, we will attempt to contact your primary care physician and obtain one. If we are unable to obtain the referral at that time, you will be rescheduled, or may elect to pay in full for all services rendered.
Payment for Office Visits and Services
Payment is expected at the time services are rendered unless other arrangements are made. Montville Oral Surgery is a participating provider for Blue cross Blue Shield Medical, Cigna and Delta Dental Preferred. For all other insurance companies we will work with you to obtain the maximum benefit allowed from your policy. We will accept assignment for those with out of network benefits.
For those patients who are not able to pay on full the day services are rendered the following options will apply.
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If You Have /Are...
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Staff Will Collect
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Medicare
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Nothing-unless the services rendered are not covered
by Medicare. In that case, our staff will review this with you
and explain or estimate your financial responsibility using
Medicare's Advanced Beneficiary Notice (ABN). Any amounts
that are patient responsibility will be collected at the time of
the visit.
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HMO
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If we have received a referral from your primary care physician,
we will collect the office visit co pay and any non-covered services
or coinsurances, based on your coverage.
If we have not received a referral from your primary care physician,
we will collect payment in full for all services performed, using your HMO's
payment schedule.
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PPO
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Office visit co pay and any non-covered services or coinsurances,
based on your coverage.
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Out of Network
PPO or HMO
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30%of our practice fee for all services rendered. We will accept assignment and generate a claim which will be submitted to your insurance company on the same day of your treatment. Once we receive the insurance payment any balance will be billed to you and any overpayment will be returned to you.
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Part C/Private Fee For Services/ Medicare Advantage
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Office visit co pays as well as all coinsurances or payments non-covered services.
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Commercial/Indemnity
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30% of our practice fee for all services performed.
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Worker's Compensation
and
Occupational Injury
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If we have verified the claim with your carrier, no payment is necessary at the time of the visit.
If we are not able to verify your claim, payment in full - based on our State Worker's Compensation payment schedule. |
Payment Plans
Montville Oral Surgery associates offers payment plans for those who need a longer period of time to settle their account.
Our policy is to collect 50% of the patient's responsibility on the date of service. We will work with you to set-up a 3 month payment plan to finalize the balance. Outstanding balances over 90 days will be charged 1.5% interest. All of this will be discussed and summarized with you by the Financial Counselor.
Our office participates with Care Credit. Please speak to the Financial Counselor for the application and approval process.
I have read, understand, and agree to Montville Oral Surgery Associates Point of Service Billing Policy.
I understand that non-covered and out of network services, as well as applicable copayments and deductibles, are my responsibility.
I authorize my insurance benefits be paid directly to Montville Oral Surgery Associates. I authorize Montville Oral Surgery Associates to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim.
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Patient Name (Printed)
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Date Patient Signature