Member financial policy

Welcome to Bend Health! We are happy you have chosen us as your Care Provider. Our mission is to provide high-quality professional medical care and member satisfaction. To avoid confusion and meet our mission goals, Bend Health wants to make members' financial responsibilities clear and easy to understand.

This form outlines our financial policy for the Neuropsych Program including the Clinical Intake as well as Neuropsychological Testing. Should you choose to pursue Neuropsychological Testing following the Clinical Intake, this document will reflect acknowledgement of the Neuropsychological Testing financial policy.

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Neuropsychological Testing

Types of Member Payments

Insurance plans vary from member to member and service to service. Bend Health makes every attempt to verify member responsibility so that you are aware of out-of-pocket costs before being seen. Ultimately, though, your insurance contract is between you and your insurance plan. Therefore, Bend Health cannot be held liable for unexpected member costs dictated by your insurance plan’s contract with you. If you have any questions regarding your contractual payment obligations, please contact your insurance plan directly.

To help you understand the types of charges, you may see from Bend Health, and we have provided definitions and examples of different types of member payment scenarios. All numbers used in these scenarios are examples, not actual amounts.

• Co-Payments: This is a specific dollar amount set by your insurance plan, which you are required to pay for each visit with your Bend Health Care Provider. Payment in most cases should be made prior to seeing your Provider.
  
  • Example: Your health plan allows $100 for your visit with us; you have a $30 copay as set by your insurance plan. You would pay Bend Health your $30 copay, and your insurance plan would cover the remaining $70 (payable to Bend Health) to equal the $100 allowed amount.
• Deductibles: This is the amount a member needs to pay out-of-pocket before their insurance company covers any expenses.
  • Example: A member has a $1,000 deductible as set forth by your insurance plan. Your insurance plan allows $100 for your visit with us. You, as the member, would be responsible for paying that $100 for every visit until you have reached your $1000 deductible.
  • NOTE: Deductibles are met through any services covered by your Insurance Plan, not just the services with Bend Health.
• Co-insurance: This is a cost-share agreement with your insurance company, which usually goes into effect after your deductible has been met, but before you have satisfied your out-of-pocket maximum. Some insurance plans do not have an out-of-pocket maximum and will always have a co-insurance agreement with you. 
  
  • Example: You have an 80/20 co-insurance policy with your insurance company. This means they agree to pay 80% of allowed charges and expect you to pay the remaining 20%. Your health plan allows $100 for your visit with us, your insurance plan would pay Bend Health $80, and you would pay Bend Health $20.
• Out-of-Pocket-Maximum: This is set by your insurance plan. It is the maximum amount you would spend out-of-pocket to pay for co-payments, deductibles, and co-insurance before your insurance plan covers all costs

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Consent for Non-Covered Services

I acknowledge and agree that I am responsible for all charges for services provided to me that are not covered by my Plan or for which I am responsible for payment under my Plan. For example, I acknowledge that Bend Health Neuropsychological Clinical Intake and/or Neuropsychological Testing  may not be a covered service under my Plan. To the extent coverage is not available, or is limited, under my Plan, I acknowledge that I am responsible to Provider for all of the Provider's charges for services furnished, and I agree to pay Provider all charges not covered by my Plan.

This Payment Responsibility Agreement MUST be executed in advance of the provision of the service or supply for which the Member is to be financially responsible for payment to the Provider and the Member must have been informed of, and specifically acknowledge, that the Member is aware that your health plan has determined that the service or supply was not Medically Necessary. In order to be considered effective and valid, this Payment Responsibility Agreement must be executed prior to the delivery of any such service or supply and the Member must have received notice of the denial (including information regarding their appeal rights).

This Payment Responsibility Agreement shall be used by the Provider in such instances and must be separate from any patient payment responsibility information that is signed by the Member at the onset of treatment or that is part of the provider or facility admission form(s).

Provider Phone: 800-516-0975

Provider: Bend Health

Provider NPI/Tax ID:

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By signing below, I agree to pay the Provider for those services or supplies that my health plan or its administrator determined were not Medically Necessary. I understand, pursuant to the Provider’s Agreement with my health plan, that a Provider may not charge me for a service or supply determined not to be Medically Necessary by my health plan unless I have specifically agreed in writing, prior to delivery of such services or supplies, to be personally responsible for and pay for such services and supplies. Prior to signing this Patient Responsibility Agreement, I understand that my health plan determined that the services and supplies listed below were not Medically Necessary and thus not covered by my health plan or insurance. I also understand that the Provider and/or I may appeal any determination that a service or supply is not Medically Necessary. I further understand nothing in this Agreement may be construed to limit any other rights I have under state or federal law. I also understand that receipt of such services or supplies without my signature below cannot be charged to me personally. 

I understand that, for the specified services and supplies listed below received after the date of signature below, I will be personally financially responsible for payment for such services and supplies directly to the Provider and that they are not covered by my health plan or insurance, even though the cost for these services and supplies may not be shown on my Explanation of Benefits (“EOB”) as my financial responsibility. I also understand that an appeal of a non-Medical Necessity determination does not assure that I will not be personally financially responsible for services or supplies related to the appeal.

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If you need further clarification or would like to speak with someone regarding the information provided above, please contact us at Billing@Bendhealth.com.