Billing Process
We welcome you to our practice as either a new patient or returning patient and would like to briefly review or update you on our billing procedures.
1.
Currently, we participate with only the military Tricare, and Medicare. We do not participate with any dental insurance plans.
2.
If you do not have one of the above insurance plans, our office will work with you to obtain reimbursement and send claim forms to your insurance company, but you are responsible for all charges.
3.
If you have Tricare Prime, we must have received a referral prior to your visit. If you are active duty there is no co-pay. If you are retired there is a $30.00 co-pay each time you have an office visit. If you have Tricare Standard or Tricare Select, you must pay the deductible plus a 25% co-pay for each procedure.
4.
f you have Medicare, to obtain coverage you will have to meet certain Medicare mandated requirements and provide all necessary paperwork prior to your initial visit. You might have to pay a small portion if your secondary insurance does not cover a particular service. Some procedures are not covered under Medicare, and you will need to sign an ABNA form and make payments.
5.
All patients need to understand that if their insurance does not cover a service that they are responsible for any balance. Please Note: If your insurance does not reimburse the Practice after two claim submissions, patient will be responsible for the remaining balance. For your convenience we accept VISA, MasterCard, AMEX, Discover, checks, and cash. Payments are due at the time of treatment.
6.
All fees and charges are due on the date of service. In the event the practice proceeds with collections any monies due over 90 days from the date of presentation of an invoice, will be the full responsibility of the patient. All attorney fees and any other costs incurred by the practice will be the responsibility of the patient.
Download & Sign
Download the form, sign and send to:
admin@novafacialpain.com
Fax: (703) 991-1177