VOB for Billing Form
Please complete the form below. *Required Fields
Sender
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Provider/Facility Name:
*
Please Select
Blossom Birth & Wellness Center
The Milk Spot
Favored Medical - Dr Hinds
TT- UNtied
Provider Email
*
CC: Patient Email
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VOB
Date:
-
Month
-
Day
Year
Patient Full Name:
*
First Name
Last Name
Insurance:
*
Please Select
Aetna
Anthem/BCBS
Blue Shield
Cigna
Health Net
Humana
Kaiser
UHC/UMR
Other
Verification Reference
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Online
Faxback
Name & Ref#
Policy Effective Date:
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Month
-
Day
Year
Benefits based on individual OR family?
Please Select
Individual
Family
NETWORK PARTICIPATION
Provider:
*
Please Select
INN with Plan
OON with Plan
Facility:
*
Please Select
INN with Plan
OON with Plan
Not associated
Care outside of Contract- Facility OON
Referral and Authorization
Referrals & Authorization Options
Plan does NOT require referral/authorization for care
Referral / authorization required from PCP to Specialist- PT must obtain
Other
PLAN BENEFITS
Plan Benefits Options
Plan Benefits
Maternity Benefits
Tongue Tie
MilkSpot
Medical Plan Benefits
Rows
Deductible
Coinsurance
OOP
Copay
Plan Benefits
Maternity Benefits
Maternity Covered Services
Rows
Home Birth
Midwives
Birth Centers
Deductible waived for global IN Network maternity?
1.
Yes-Collect per claims processing
No
Not Specified on Plan
Yes
No
Not Specified on Plan
Yes
No
Not Specified on Plan
Yes
No
Mother Breakdown of Care
Rows
copay
ded
coinsurance
OOP
total
Initial ($250)
Global Provider ($2500)
Global Facility ($2000)
Ultrasounds x2 ($165/$330)
Non-Contracted Facility Care ($1000)
Total Mother amount
Newborn Breakdown of Care
Rows
copay
ded
coinsurance
OOP
total
Newborn Care
Total Newborn amount
Total Family Responsibility *estimate
Total Patient Responsibility *estimate
Congratulations!!! from Blossom Birth & Wellness Center
Congratulations!!! from Blossom Birth & Wellness Center
Congratulations from Blossom Birth & Wellness Center on your pregnancy! Thank you for your interest in pursing care here! Above is the information you requested regarding your insurance coverage with us. Insurance plans separately contract medical providers and the facility where care takes place. Services at Blossom Birth & Wellness Center utilize both the care provided by each individual midwife ("provider") but also the care provided at Blossom as a medical licensed facility (the additional staff, assistants, use of the sonogram machine, blood draws, phone calls, etc). The copay, coinsurance, and/or deductible amounts cover all routine care for mother (prenatal visits, labor/delivery, and postpartum visits). Labs, ultrasounds, non-stress tests, IV fluids, and non-routine problem visits are billed to insurance separately and may be subject to your unmet plan patient responsibility. For this reason, you can see that the ultrasound price is listed separately and there is a "facility" cost to cover the other aforementioned additional care. The separate "newborn care" cost, as applicable based on your insurance plan, covers all care that Blossom will provide to your baby after delivery. A minimum payment of $500 is due at your first prenatal visit. It will go towards your total estimated financial responsibility. Monthly payments are due thereafter, paying off the balance by 32 weeks of pregnancy. When making payments, there is a 3% card surcharge. If you'd prefer to avoid the surcharge, Blossom accepts checks, cash, and zelle.
OTHER INFORMATION
Notes
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