MOSAIC UNLIMITED, INC.
9 JUNCTION DRIVE WEST, SUITE 3, GLEN CARBON, IL 62034
Payment/Insurance Verification Form (Page 1 of 2)
Choosing to bill for counseling sessions through your insurance carrier is an important decision you must make. According to federal regulations, you may choose to ‘opt’, pay out-of-pocket, and NOT bill through your insurance policy. Clients who ‘opt’ are private pay clients. Should this be your preference, Mosaic Unlimited, Inc. would NOT have the authorization to share your records with your insurance company. The decision made at the outset of services regarding payment of services is changeable at any time by completing a new form and updating your file. However, the fee or payment option is not retroactive and only changes for subsequent sessions.
Here is an example. Let’s say you opt to be a “private pay client” in January, and pay for services at $145.00 per session for 4 weeks. You cannot change your status from private pay client to Insurance Client for those January dates of service. If you decide to bill insurance for your February sessions, you would need to complete a new form expressing that preference, and your rates would reflect that change for your February sessions and all subsequent sessions as long as that is your expressed preference. Keep in mind if you choose to use insurance benefits, the insurance company will have instant access to your records. In addition, you will be responsible for deductibles and co-pays for subsequent sessions.
Knowing your out-of-pocket expenses prior to receiving services is your right and your responsibility.
Select a box:
o I choose to be designated as a private pay client at Mosaic Unlimited, Inc.. I will pay for sessions out-of pocket with cash, check, or credit card, in accordance with my signed contract for services. I do not authorize Mosaic Unlimited, Inc., its agents or employees, to share my private information with my insurance company.
o I choose to bill my insurance company for mental health services. I understand that if Mosaic Unlimited, Inc. is in-network with my carrier, my rates may be discounted in accordance with their business contract. I understand that if Mosaic Unlimited, Inc. is out of network with my insurance company, I am responsible for co-pays, deductible payments, or any portion of the session fees not covered by my plan. I grant this permission to be effective as of the date of my signature and witnessed by a representative of Mosaic Unlimited, Inc.
INITIAL ____ I understand that Mosaic Unlimited and my insurance company can terminate network contracts at any time and neither is required by law to inform me of this change. However, Mosaic Unlimited will make every effort to communicate any contractual change via letter, telephone call or in person. This change will affect my financial responsibility for subsequent sessions.
I authorize the release or exchange of information from Mosaic Unlimited, Inc. to my insurance company, EAP, managed care group, and/or other paying organization to facilitate payment and continued coverage under the mental health benefit of my policy. I consent to have Mosaic Unlimited, Inc. submit claims on my behalf to my insurance company, EAP, managed care group, or other paying organization and receive payment according to the guidelines of my policy. I understand that I am responsible for payment for services rendered by Mosaic Unlimited, Inc. regardless of reimbursement for these services by the insurance company and that any inaccuracy in information on this form may result in nonpayment by my insurance company. I agree to notify Mosaic Unlimited, Inc. as soon as I am aware of any changes in my health condition or health plan coverage.
______
Client or Parent/Guardian SIGNATURE DATE
______
Mosaic Unlimited, Inc. EMPLOYEE/AGENT DATE
***Back of page is a list of questions to verify your mental health benefits with insurance.
Payment/Insurance Verification Form (Page 1 of 2)
PROVIDER INFORMATION: Renee Keller, LCSW at Mosaic Unlimited
Mosaic NPI: 1124379755 Renee Keller NPI: 1487841714
Primary Mental Health Insurance: ______Telephone #: ______
Date Contacted: ______Representative’s Name:______
In-Network Providers Out-of-Network Providers
Deductible for Individual Sessions:Annual effective date and amount:
Deductible amount met as of today: / Individual Session: Yes/No
Date:______
$______
$______/ Individual Session: Yes/No
Date:______
$______
$______
Deductible for Couples or Family Sessions:
Annual effective date and amount:
Deductible amount met as of today: / Couples or Family Sessions: Yes/No
Date:______
$______
$______/ Couples or Family Sessions: Yes/No
Date:______
$______
$______
Are the following mental health services covered:
Is pre-authorization required?
What is the co-pay or percentage I am responsible to pay?
Is there a limit on number of visits per year? / 45 Min (90834) Yes/No
55 Min (90837) Yes/No
Group (90853) Yes/No
Complexity (90785) Yes/No
Yes/No
Co-pay $______or %______
Yes/No
If yes, number of visits used this year ______/ (Write below if coverage differs for out-of-network)
______
______
______
Yes/No
Co-pay $______or %______
Yes/No
If yes, number of visits used this year ______
Do you have a ‘Health Savings Account?’ Yes/No
*Important question to ask your insurance representative for out-of-network reimbursement:
“What is the process to get reimbursed for out-of-network services?”
Each insurance company has a different reimbursement process. Ask your insurance carrier’s reimbursement requirements and copies of the necessary forms.
Verifying benefits does not guarantee payment for services.
Phone: 618.407.0900 Fax: 618.205.3561 www.metrostltherapy.com