ATLZ05 Financial Responsibility Notice

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FINANCIAL RESPONSIBILITY NOTICE

Atlantic Prosthetics & Orthotics, LLC will verify your insurance benefits and bill your insurance company as a courtesy; however verification of benefits is not a guarantee of payment.

Upon verification of benefits, you will be made aware of your benefits as quoted from your insurance company, and given an estimated amount that you will need to pay prior to, or upon delivery of your device. If this amount is more than your deductible and/or coinsurance responsibility, you will be refunded any amounts overpaid after your claim is processed by your insurance company. If the amount you have paid is less than your deductible and/or coinsurance responsibility, you will be billed for the additional amount after your claim is processed by your
insurance company.

I request that payment of authorized Medicare, Medicaid or Private Insurance benefits be made to Atlantic Prosthetics & Orthotics, LLC for any covered items or services that I have received.

I agree to assume financial responsibility for any claim or portion of the claim due to Atlantic Prosthetics & Orthotics, LLC for services provided, not covered by the insurance policy. If the insurance company denies coverage for a product, I agree to assume financial responsibility for its payment.

* * I have read the above Financial Responsibility Notice for Atlantic Prosthetics & Orthotics, LLC. I understand the financial process described in this notice and my signature indicates that I am in agreement with the terms listed above.
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I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
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Atlantic Prosthetics & Orthotics Financial Policy

Thank you for choosing Atlantic Prosthetics & Orthtics! We are committed to the success of your care. Our administrative staff is available to answer any specific billing questions. The following information is provided as a courtesy to claify your financial responsibility relatedto services provided by Atlantic Prosthetics and Orthotics. This document does not cover all situatinos and should not be construed to ba an all-inclusive listing of all possible situations. If a specific payer contract (including Medicaid or Worker's Comp) is in conflict with any of the policies below, then the payer contract will supersede the conflicting policies. As part of our commintment of service to you, we will make every attempt to verify your insurance benefits at the time your services are rendered. However, insurance verification or authorization is not a guarantee of insurance payment. This only allows our office to provide you with preliminary estimate of any monies due by the insured at the time of delivery of the device. Your patient portion is subject to change based on final claim determination by your insurance carrier.

What is My Financial Responsibility for Services? Your financial responsibility depends on a variety of factors, explalined below:

If you have...	You are Responsible For...	Our Staff Will...
Insurance Plan: In Network	If the services you receive are covered by the plan: You pay deductible and co-insurance on or before date of delivery. If the services you receive are not covered by the plan: Payment in full on or before date of delivery.	Contact your insurance plan to obtain your eligibility, benefit information and patient portion (deductibles, co-insurance, etc.) Submit your insurance claim.
Insurance Plan: Out of Network	Payment in full on or before deliver, unless your plan agrees to pay us directly.	Contact your insurance plan to obtain your eligibility and Out-of-Network benefit information Submit your insurance claim if your plan agrees to pay us directly.
Medicare Part B	If you have Medicare Part B. and have not met your deductible, we ask that it be paid on or before date of delivery. If you don not have secondary insurance Medicare co-insurance amount on or before date of delivery. If the total services are less than $200 full payment on or before date of delivery. Payment for any services not covered by Medicare on or before date of delivery	Contact Medicare and secondary insurance plan (if applicable) to obtain your eligibility and benefit information. Submit your insurance claim to Medicare, as well as any claims to your secondary insurance.
Medicaid	Depending on each State's Medicaid Program. if the services you receive are covered by Medicaid: patient portion (if applicable) on or before date of delivery. Payment for any services not covered by Medicaid on or before date of delivery.	Contact Medicare and secondary insurance plan (if applicable) to obtain your eligibility and benefit information. Submit your insurance claim to Medicare, as well as any claims to your secondary insurance. Medicaid Depending on each State's Medicaid Program. if the services you receive are covered by Medicaid: patient portion (if applicable) on or before date of delivery. Payment for any services not covered by Medicaid on or before date of delivery. Contact local Medicaid office to obtain your eligibility, benefit information and patient portion (if applicable) as well as obtain prior authorization (if applicable).
Worker's Compensation	If the services you receive are covered by Worker's Comp: patient portion (if applicable) on or before date of delivery. Payment of any services not authorized by Worker's Comp on or before date of delivery.	Call your Worker's Comp plan to obtain your eligibility, benefit information and patient portion (if applicable) as well as obtain prior authorization (if applicable).
No Insurance	Payment in full before date of delivery.	Advise you regarding charges for services provided. Advise you regarding Financial Assistance.

How may I pay? We accept payment by: Cash, Check, Credit (MC, VISA, AMEX and Discover Card). Note: Charges not covered by your insurance plan, as well as applicable co-payments, co-insurance and deductibles, are your responsibility. Our returned check fee is $25.00.

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain billing privileges. These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).
1. A supplier must be in compliance with all applicable federal and state licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services.
2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
3. An authorized individual (one whose signature is binding) must sign the enrollment application for billing privileges.
4. A supplier must fill orders from its own inventory or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs or from any other federal procurement or non-procurement programs.
5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment and of the purchase option for capped rental equipment.*
6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable state law and repair or replace free of charge Medicare covered items that are under warranty.
7. A supplier must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier's compliance with these standards.
9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.
10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier's place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
11. A supplier is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR 424.57 (c) (11).
12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items and maintain proof of delivery and beneficiary instruction.
13. A supplier must answer questions and respond to complaints of beneficiaries and maintain documentation of such contacts.
14. A supplier must maintain and replace at no charge or repair directly or through a service contract with another company Medicare-covered items it has rented to beneficiaries.
15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
16. A supplier must disclose these standards to each beneficiary it supplies a Medicare-covered item.
17. A supplier must disclose any person having ownership, financial or control interest in the supplier.
18. A supplier must not convey or reassign a supplier number (i.e., the supplier may not sell or allow another entity to use its Medicare billing number).
19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
20. Complaint records must include the name, address, telephone number and health insurance claim number of the beneficiary; a summary of the complaint; and any actions taken to resolve it.
21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.
22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). Implementation Date - October 1, 2009.
23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
26. A supplier must meet the surety bond requirements specified in 42 C.F.R. 424.57(c).
27. A supplier must obtain oxygen from a state-licensed oxygen provider.
28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f)
29. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.
30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848 (j) (3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.
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