Self-pay (out-of-network) clients:
I will provide you with a superbill suitable for you to submit to your insurance. The superbill (which will also serve as a payment receipt) will be coded appropriately to the level of service provided during the visit. You agree to pay me at the time of the visit (cash, check, credit card, or FSA).
Insurance (in-network) clients:
Claims for my care will be submitted directly to your insurance. The Mama's Dula LLC will appeal all cost-sharing under the Affordable Care Act which states that lactation services are preventive and not subject to cost-sharing. If my insurance provider applies any portion to deductible or coinsurance and appeal attempts are unsuccessful, my credit card on file will be charged. If that charge is unsuccessful for any reason, I will be invoiced and I agree to pay within 7 days for all applied charges for all visits.
The Mama's Dula LLC will submit a claim on behalf of myself and my babies. If any portion of either claim is applied to cost-sharing, I understand that I am required by law to pay cost-sharing to The Mama's Dula LLC. My credit card will be charged upon receipt of the Estimation of Benefits (EOB) by The Mama's Dula LLC. Every effort will be made to have my insurance recognize these claims as preventive and not subject to cost-sharing, and an appeal will be initiated. If successful, I will be refunded any amount that The Mama's Dula LLC recovers from my insurer.
If one of us (me or my baby) is on different insurance and therefore out-of-network for The Mama's Dula LLC, I agree to pay $XX per visit. I will receive a superbill for this amount and can submit for out-of-network insurance.
If I have different primary insurance that is out-of-network for The Mama's Dula LLC, I understand that I must pay the full self-pay fee up front as a deposit. I will not be refunded for any amount either insurance applies to cost-sharing. I will only be refunded if and when The Mama's Dula LLC receives payment directly from either insurance, and only for the specific amounts paid by my insurance(s). The Mama's Dula LLC may keep any amount paid by my insurance(s) over and above the deposit I paid.
The Mama's Dula LLC is providing care to me and to my baby or babies; together we are all the client of The Mama's Dula LLC.
My initial visit includes 1 week of follow up support by secure messaging, email, or text. Continued support is available for a weekly fee of $25. These fees are elective and not eligible for insurance reimbursement.
If my location has a travel fee applied, I understand that this is not eligible for insurance reimbursement.
I am responsible to verify my own lactation benefits. The Mama's Dula LLC can only see that I have benefits, they cannot see if I have any special circumstances that might prevent my insurance provider from covering services. If my plan denies coverage of lactation services after the claims have been submitted, I am responsible to pay at the self-pay rate. I understand I should refer to my plan benefits and call my insurance directly to verify lactation coverage.
The Mama's Dula LLC may communicate with my insurance company in reference to the services provided to me and my baby or babies. The Mama's Dula LLC may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information. I will update my credit card information as needed and am responsible for any costs and fees associated with my failure to provide updated information.
These policies apply to The Mama's Dula LLC and its representatives.
Payments may be made electronically using a credit card or fund transfer. I use SquareUp to process payments. SquareUp meets the high standards of HIPAA and the banking industry for security and privacy with regard to financial transactions. However, SquareUp may send, automatically or per your request, email or text message receipts that reveal personal health information such as the date and type of lactation visit. If you are not comfortable with this, payment may be made via cash or check instead.
Cancellation policy: I understand that I am responsible for all charges associated with this visit. If I cancel with less than 24 hours notice, my credit card on file will be charged $50.
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