Financial Policy and Terms of Payment
Our Financial Polies and Fees
Thank you for choosing Tranquility Behavioral Health LLC as your mental health provider. We are dedicated to offering exceptional care tailored to your needs. To ensure clarity and fairness, we request that all patients review, understand, and consent to our financial policy before receiving services. Compliance with this policy is mandatory, and patients cannot be seen without signing this document.
Copayments and Coinsurance
As per our contracts with insurance companies, we are required to collect all co-pays and co-insurance amounts at the time of service. We cannot waive these fees under any circumstances. Payments may be made using cash, Visa, MasterCard, Discover, or debit cards
Deductibles, Coinsurance, and Out-Of-Pocket Costs
For patients whose deductibles have not been met, we will collect the following amounts: New Patient Evaluation: $300 Follow-Up Visits: $125 Once your insurance company processes the claim and provides an Explanation of Benefits (EOB), your account will be reconciled, and any necessary credits or adjustments will be applied.
Testing and Non-covered Services
Certain services, including but not limited to neurocognitive and specialized testing, are not covered by insurance. These services must be paid in full at the time of scheduling. The charges for these services are as follows: ADHD Testing: $195 Autism Testing: $225 Concussion Testing: $225 Mild Cognitive Impairment Testing: $250 Pharmacogenetic Testing: $75 Nutrigenomics Testing: $100 Pharmacy Change Fee: $15 These services are considered elective and are not billable to insurance companies. Any attempt by an insurance company to require billing for these services will not alter this policy. By signing this agreement, the patient acknowledges full financial responsibility for these services.
Supportive Psychotherapy During Medication Management Visits
Supportive psychotherapy is provided as a therapeutic part of medication management visits using CPT code 90833. This service is integral to comprehensive care but is frequently denied by insurance companies or deemed "not medically necessary." Patients are financially responsible for charges related to supportive psychotherapy if not covered by insurance. By signing this policy, you acknowledge your financial responsibility for these services.
Legal Proceedings/Court-Related Services:
We do not provide evaluations or reports for custody, visitation, or other forensic matters. We cannot and will not offer testimony or reports regarding custody, visitation, or parental fitness in legal or administrative proceedings. If such services are needed, you must hire a mental health professional specializing in forensic cases.
Reasons for This Policy:
A provider-client relationship may create a perception of bias.
Testimony could compromise the therapeutic relationship and the confidentiality of your mental health treatment.
Forensic evaluations are best conducted by professionals trained in court-related matters.
By signing below, you waive the right to request our participation in legal proceedings. If a subpoena is issued, a $5,000 retainer fee is required in advance for any court-related involvement.
Billing Codes for Medication Management and Services
The following CPT codes are used for billing medication management and related services:
Medication Management Visits: 99212, 99213, 99214, 99215
New Patient Evaluation: 90792 and/or 99205
Supportive Psychotherapy: 90833 (insurance may or may not cover this code) Fee if not covered $45
Nursing Services: Includes pharmacy calls, prior authorizations, continuity of care, callbacks from the nurse, preparation of samples for patients unable to obtain prescribed medications immediately, patient education, care coordination with other providers, and medication reconciliation. $25 per encounter
Please note that we do not bill insurance for any of our testing services, and all testing charges must be paid out of pocket, as detailed above, and are the responsibility of the patient.
Out-of-Network Providers
If we are not in-network with your insurance, you will be responsible for the entire cost of the visit at the time of service. Upon request, we can provide you with a Superbill to submit to your insurance company for potential reimbursement.
Drug Screen Fee
A $25 fee will be charged for all drug screenings conducted as part of your treatment plan. This fee is not covered by insurance and is the responsibility of the patient. Payment is due at the time of service.
By signing below, you acknowledge and agree to this policy.
Refunds and No-Show Policy
Refunds: No refunds are provided after a service has been rendered or for missed appointments.
No-Show Fees:
New Patient Appointments: $300
Follow-Up Appointments: $125
If you fail to attend your appointment or leave before being seen by the provider, it will be considered a no-show, and the above fees will apply.
Changes to Insurance or Payment Method
Please notify our billing department within 72 hours before your appointment if you need to change your payment method or update your insurance information. Failure to do so will result in rescheduling until insurance verification is complete.
Paperwork Policy
We understand that patients may require completed forms for disability or work-related purposes. However, please note that we no longer provide support for FMLA (Family and Medical Leave Act), short-term disability (STD), or long-term disability (LTD) claims due to the complexities involved. For all other paperwork-related requests, we have established the following fee scale: Paperwork Fee Scale: -Diagnosis and/or Treatment Physician Letter: $100.00, plus $15 Notarization fee (paid directly to in-house Notary) -Authorization Letter to Administer -Medication by a School Nurse: $30.00 -Educational 504 Accommodations Letter -Emotional Support Pet Letter: $100.00, plus $15 Notarization fee (paid directly to in-house Notary) -Legal/Disability-Related Medical Record Processing Fee (20 pages or less): $25.00, plus $15 Notarization fee (paid directly to in-house Notary) -Medical Record Processing Fee (More than 20 pages): $75.00, plus $15 Notarization fee of Medical Records (paid directly to in-house Notary) -VA Disability Paperwork: $450.00, plus $15 Notarization fee (paid directly to an in-house Notary) -Service Dog/ESA Letter $100, plus $15 Notarization fee (paid directly to the in-house Notary) -Medical Notarizations: $15.00 - $25.00 -Prior Authorization (medication) $20 -Treatment Verification Form $75
Terms of Payment
Payment Responsibility: Payment for services is the responsibility of the patient or their legal guardian. Full payment is due at the time of service unless prior arrangements have been made.
Accepted Payment Methods: We accept cash, credit/debit cards, and approved health savings account (HSA) cards. Checks are not accepted.
Insurance Billing: As a courtesy, we may bill your insurance provider. Patients are responsible for any co-pays, deductibles, or services not covered by their insurance plan.
Non-Covered Services: Patients are responsible for fees related to services not covered by insurance, including no-show fees, late cancellations, and certain specialized treatments.
Missed Appointments and Cancellations: A fee may be charged for missed appointments or cancellations made with less than 24 hours' notice.
Outstanding Balances: Balances not paid within 30 days may incur a late fee. Accounts overdue by more than 60 days may be subject to collections.
Payment Plans: Payment plans may be available for eligible patients upon request. Please speak with our office for further details.
Questions or Concerns: If you have questions about your bill or need financial assistance, don't hesitate to contact our office at 832-879-2107.
By signing below, you acknowledge your understanding and agreement with this financial policy.
Balances and Billing
All balances, including co-pays, co-insurance, and deductibles, must be paid prior to receiving services.
We will bill your insurance company as a courtesy, but you are responsible for any remaining balance not covered by insurance.
If payment from your insurance company is not received within 30 days, you will be responsible for the full cost of the visit.
If your insurance deems a claim as "not medically necessary," you will be financially responsible for the cost of the visit.
No Surprise Act
Pursuant to the No Surprise Act, you are entitled to receive a Good Faith Estimate (GFE) for the expected costs of non-emergency care. If you receive a bill that is at least $400 higher than your GFE, you may dispute the bill. For more information, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Insurance Coverage Disclaimer
Verification of insurance coverage is not a guarantee of payment for services. It is your responsibility to understand your insurance benefits, including coverage, co-pays, co-insurance, and deductibles. Any services denied or not covered by your insurance will be billed to you directly
Legal and Financial Protections
Tranquility Behavioral Health LLC retains the right to adjust fees periodically. Notification of fee changes will be provided before your next appointment. By signing this policy, the patient agrees to:
Take full financial responsibility for any balances, denied claims, or non-covered services.
Refrain from disputing charges for non-covered services that were clearly communicated as not billable to insurance.
Abide by the terms outlined in this financial policy.
Patient/Guardian/Parent Signature:
I have read and understand the financial policy of Tranquility Behavioral Health LLC. I agree to comply with the terms and conditions outlined above. I understand my financial responsibilities and the practice's payment policies. I acknowledge the above financial policy by typing my name in the box below.
