Insurance and Fees Agreement

As a courtesy to you, we will gladly file your claims for most insurance companies; however, it is your responsibility to handle any problems with your insurance company.

You are responsible for any deductible and co-insurance or co-pays.

We will do our very best to help you understand your insurance benefits, however, we do not guarantee anything about your insurance. All payment decisions are made by your insurance company upon their receipt of claim, based on your benefit plan. It is your responsibility to know your insurance coverage, including any pre-authorizations that your policy may require.       

Insurance Cards: In order to verify your benefits, a copy of the front and back of your Insurance card must be uploaded. Without a copy of your card prior to this appointment, we will be unable to determine coverage, cost and/or limitations. If you are unable to upload our card, a copy of your insurance card must be brought to your first appointment.                                                                                      

Occasionally, insurers will pay a beneficiary instead of the provider. If any payment is made directly to you for services billed by KIDSPEAK SPEECH AND LANGUAGE SERVICES, you recognize an obligation to promptly remit the same payment to KIDSPEAK SPEECH AND LANGUAGE SERVICES within 15 business days upon receipt. If an insurance payment is made to you directly, by signing below, you agree that the total payment will be turned over to the KIDSPEAK SPEECH AND LANGUAGE SERVICES (the provider), and that failure to cooperate with this agreement will result in the beneficiary no longer being accepted as a patient.

I understand that for any period of time when the patient is eligible for Medicaid or its related programs (Healthy Connections, Partners for Healthy Children, First Choice/Select Health, PEP, ATC/WellCare, BlueChoice, and/or other programs that may be developed), KIDSPEAK SPEECH AND LANGUAGE SERVICES may bill the Medicaid program for those services and Medicaid may pay KIDSPEAK SPEECH AND LANGUAGE SERVICES for providing those services. KIDSPEAK SPEECH AND LANGUAGE SERVICES has permission to bill Medicaid retroactively for services performed prior to the date of this consent. In accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d et seq.) and regulations pursuant thereto (45 C.F.R Part 80), upon notification and/or request of the patient’s parent or guardian, KIDSPEAK SPEECH AND LANGUAGE SERVICES will take steps to ensure that Medicaid members with limited English skills receive at no cost to the member, the language assistance necessary to afford them meaningful and equal access to the Medicaid benefits and services to which they are entitled.

If the patient is not eligible for Medicaid services under South Carolina Medicaid on the date of service, reimbursement for all services provided must be resolved between the provider (KIDSPEAK SPEECH AND LANGUAGE SERVICES) and the payee/responsible party for the patient receiving services. Providers are not required to accept Medicaid for services provided during the patient’s retroactive eligibility period and may continue to bill the patient for those services. Providers may choose to accept Medicaid for the services provided during the patient’s retroactive eligibility period; however, it may not extend a 60-day period. KIDSPEAK SPEECH AND LANGUAGE SERVICES will honor retroactive eligibility up to 60 days from the date of initial Medicaid eligibility. Occasionally, insurers will pay a beneficiary instead of the provider. If an insurance payment is made to a parent/patient directly, by signing below, the parent/guardian hereby agrees that the total payment will be turned over to the KIDSPEAK SPEECH AND LANGUAGE SERVICES (the provider), and that failure to cooperate with this agreement will result in the beneficiary no longer being accepted as a Medicaid patient.

All fees are due at the time services are rendered.

If your child discontinues therapy with our center and has a balance on his or her account, there will be a $5.00 billing fee. If your bill is not paid in a timely manner, a $30.00 late fee will be assessed to your balance. You will also be responsible for collection fees if your account is turned over to collections.

I fully understand that I am responsible for any balance due to KidSpeak Speech and Language Services that insurance has not paid within 30 days of the visit. I understand that if services are non-covered, I am responsible for the full amount of the charge. I understand that it is my responsibility to work out any issues with my insurance company regarding non-payment of claims.