Schedule of Fees

Description	Fee
New Patient Evaluation (typically 70-90 minutes)	$600.00
Follow-up Appointment (typically 20-30 minutes)	$165.00
Formal Developmental Testing	$225.00

Insurance Information

Dr. Thingvoll is currently a participating provider (“in network”) with the following insurance plans (updated 11/1/2017):

NC Medicaid

BCBS of NC

Medcost

Crescent

Healthscope

Tricare

It is important that you understand your insurance benefits. Your insurance is a contract between you and your insurance provider, and there is no guarantee of benefits. Your insurance company will only pay for services covered under your contract. We urge you to contact your insurance company before your appointment to ask about pre-authorization requirements and coverage for subspecialty developmental pediatric care, including developmental testing (CPT code 96111) in order to reduce the chance of claim denial. In the event that some or all of your services are not covered by your insurance plan, you will be responsible for 100% of these charges at the time of your visit.

If you have one of the above listed insurance plans, we will file the claim on your behalf. Please provide your insurance information on the New Patient Intake Form and bring your insurance card to the first appointment. If you fail to do so, you will be responsible for full payment at the time of your appointment.

Payment

Payment is due in full at the time of your appointment. We accept payment in the form of cash, checks, VISA and Mastercard. There is a returned check fee of $35.00.

For patients with insurance that Dr. Thingvoll is a participating provider, you will required to pay all co-pays, co-insurance, and deductibles at the time of your appointment.

For patients without insurance or with insurance that Dr. Thingvoll is NOT a participating provider (“out of network”), fees will be charged according to the fee schedule above. For these patients, you will be provided with an itemized statement with all of the required information that you can submit to your insurance company for reimbursement. For these patients, we still encourage you to call your insurance company before your appointment to ask about pre-authorization requirements and covered services.

Credit Card Policy

We require a valid credit card to be on file in order to schedule an appointment. This credit card will be used to charge “no show” and “late cancellation” fees (see below) when appropriate. We will notify you at the time we remit these charges. Any balance due after your insurance claim is processed will be billed directly to you. Credit card information will be stored in a PCI (Payment Card Industry Security Standard) compliant database through TransFirst Health. Please note that Medicaid patients will not be required to have a credit card on file.

Missed Appointments (No Shows) and Late Cancellations

Due to the complex nature of developmental pediatric evaluations and the amount of time scheduled for these evaluations, no shows and late cancellations (less than 48 business hours before the scheduled appointment time) will be charged according to the schedule listed below. Charges for no shows and late cancellations will be applied to the credit card on file. Please note that Medicaid patients will not be charged for missed appointments or late cancellations. Medicaid patients who do not show up for their appointment will be discharged from the practice and not allowed to reschedule. Medicaid patients who cancel less than 48 business hours before their appointment may be rescheduled at our discretion.

Description	Fee
Missed Appointment/No Show – New Patient	$200.00
Missed Appointment/No Show – Follow-up	$75.00
Late Cancellation (less than 48 hours notice)	$75.00

Unpaid Balances

Should there be a payment balance due to claim denial, uncovered services, or changes to your insurance plan, you will be billed for the balance. Unpaid balances 60 days after sending the bill will be charged to the credit card on file. Should the credit card not be valid, and an alternative payment arrangement not agreed upon, legal means might be used to secure payment, which may include hiring a collection agency.

Phone Consultation and Other Services

We provide telephone care free of charge to answer routine questions regarding the evaluation and treatment of your child, including prescription refill requests, medication dosage questions/adjustments, medication side effects, follow-up on any test results, referrals or other basic questions.

Occasionally, there is a need for more involved, complicated telephone consultation that requires physician expertise and time as well as clinical documentation. These services are billable and not covered by insurance companies. Other billable services include the completion of school, medical and legal forms and writing school, medical or legal letters. Results of your evaluation will be faxed to the referring provider and mailed to the parent/guardian. Additional copies of the medical record require a nominal fee. These services are billed after the encounter according to the schedule below. Please note that the charge for these services will include documentation time.

Description	Fee
Physician Phone Consultation (longer than 5 minutes)	$25.00 per 10 minutes
Completion of Any Forms or Writing Letters	$25.00 per 10 minutes
Additional Copies of Medical Record (includes shipping)	$10.00
Other Services Not Listed	Negotiable, typically $25.00 per 10 minutes