Billing and Financial Responsibility Policy
Columbia Medical Associates (CMA) participates with many insurance plans. CMA will submit a claim for services to your insurance company. Based on your coverage you may be responsible for some (or all) services you receive as they may be
non-covered or considered not medically necessary. CMA will bill your insurance for all services rendered, it is the responsibility of the patient to know your insurance plan. CMA will verify eligibility for the information supplied. If your insurance is not eligible we will make good effort to contact you before your appointment letting you know. If no insurance coverage can be verified you will be responsible to pay for services at time of visit.
Responsibility of CMA:
· To bill all claims to your insurance carrier(s) on your behalf
· To assist you with resolving claims issues regarding payments
Responsibility of Patient:
· To pay your copay, coinsurance, or deductible at time of service
· To provide accurate Insurance information at time of visit so CMA can submit your claim correctly
· To pay any remaining account balance after insurance has paid within 60 days of receipt of your first statement
Insurance: Columbia Medical Associates accepts most insurance plans with the most common insurance plans listed below. Please contact our office if you have questions regarding your insurance plan at 509-688-6700.
· Group Health / · Premera / · United Healthcare· Cigna / · Aetna / · Medicare
· First Choice Health Network / · Molina / · Coordinated Care
Please initial.
/ Payment: Columbia Medical Associates accepts cash, credit card, and personal checks as form of payment. If 2 or more checks are returned from your bank you will be required to use another form of payment and will be charged $45.00 for each returned check
/ Self-Pay patients: This status is reserved for patients that do not have any medical insurance coverage. Columbia Medical Associates has a flat rate fee schedule for patients with no insurance. If you would like to speak to a specialist about resources that could help you get medical coverage please call 509-688-6711. Payment for self-pay patients is due at time services are rendered
/ Workers Comp & L&I: If you are involved in an incident or accident at work that will result in your medical claims being billed to Labor and Industries instead of your medical insurance coverage , please know that all necessary information to bill L&I will be required at time of service. You will be required to fill out the necessary paperwork for L&I. As a courtesy, if your claim is denied or closed CMA will bill your private insurance.
/ Third Party: If you are involved in an incident/accident (MVA, slip and fall, etc.) that will result in your medical bills being paid by an entity other than your medical Insurance coverage, please note that all necessary information to bill will be required at time of visit to Columbia Medical Associates. If you would like us to bill a third party payer we will need the following:
· Insurance company name, Policy holders name, address and phone number; full claim number; claim contact person
If payment is not received within 90 days Columbia Medical Associates will be billing you for the full financial responsibility and you will need to provide this information to the Third Party payer for reimbursement.
/ Opt Out: I understand I have the right to NOT bill my medical insurance coverage or any third party entity. I understand I will be completely financially responsible for all services rendered.
I acknowledge I have received, read and understand Columbia Medical Associates billing and financial responsibility policy
and that I will comply with these policies.
Signature:______Date:______
Print Name:______Date of Birth:______
Revision 12/01/2016