INSURANCE BILLING AGREEMENT
1. CONSENT FOR USE & DISCLOSURE OF HEALTH INFORMATION
I authorize my midwife or midwifery practice (“Provider”) to share with Billing for Littles, the maternity services division of Lyons Medical Billing, the health, demographic, insurance, and other information necessary to provide billing services on the Provider’s behalf.
I authorize Billing for Littles to use and disclose information as necessary for billing and insurance purposes, including preparing and submitting claims, communicating with my insurance company, and assisting with claim processing.
2. PRIVACY
Billing for Littles handles patient information in accordance with applicable privacy and security requirements. Information obtained through this registration or from my Provider will be used as necessary to provide billing services on behalf of my Provider.
3. INSURANCE BILLING, PAYMENTS & PATIENT COOPERATION
I understand and agree that:
Insurance claims will be submitted based on the fees my Provider sets.
My insurance company may issue payment directly to me rather than to my Provider.
If I receive an insurance payment related to services provided by my Provider, I agree to promptly notify my Provider and provide a copy of the insurance payment and Explanation of Benefits (EOB).
My Provider will determine how any insurance payment is applied to my account in accordance with my financial agreement with my Provider and applicable insurance requirements.
I agree to reasonably cooperate with requests from my Provider or Billing for Littles for information or documentation needed to process or reconcile my insurance claims.
4. REFUNDS & CHANGES IN BILLING NEEDS
The $165 billing fee covers enrollment and ongoing insurance billing services throughout my care. Because claims are submitted on an ongoing basis, I understand that I should enroll in billing services as early as possible to allow claims to be submitted in a timely manner.
If Billing for Littles is unable to provide billing services because my Provider does not work with Billing for Littles, my payment will be refunded, less the 3% payment processing fee.
If I no longer need billing services before billing has begun, I may request a refund of the amount paid, less the 3% payment processing fee.
If billing services have begun and I transfer care or otherwise discontinue services before 36 weeks of pregnancy, I may request a $75 refund.
At 36 weeks of pregnancy or later, the billing service is nonrefundable.
I agree to notify Billing for Littles as soon as possible if I transfer care, change insurance coverage, or otherwise no longer require billing services.
5. SCOPE OF BILLING SERVICES & LIMITS OF RESPONSIBILITY
Billing for Littles provides insurance billing services on behalf of my Provider. I understand and agree to the following:
A. Claim Preparation, Submission & Follow-Up
Billing for Littles will:
Prepare and submit insurance claims using information and medical documentation provided by my Provider;
Apply appropriate billing and diagnosis codes based on the documentation provided;
Submit claims according to applicable billing guidelines; and
Monitor submitted claims and assist with routine claim-processing issues, corrections, and requests for additional information when reasonably possible.
I understand that accurate claim preparation and submission does not guarantee coverage, payment, or reimbursement by my insurance company.
Verification of Benefits (VOB) is not included in the $165 billing service and must be purchased separately, if desired.
B. Appeals & Insurance Disputes
If a claim is denied, reduced, or otherwise requires an appeal, Billing for Littles will provide support to help me understand my appeal options and next steps.
Because my Provider may be out-of-network with my insurance plan, the first approach will generally be for me, as the insured member, to initiate the appeal. I understand that I may have appeal rights, online tools, and access to my insurance company that are not available to my Provider or Billing for Littles.
To support me with an appeal, Billing for Littles may:
Review the insurance company’s denial or claim determination with me;
Explain available appeal options and suggested next steps;
Provide claim information, insurance communications, and other information Billing for Littles has collected regarding my case;
Provide relevant billing documentation; and
Prepare an appeal letter or other supporting documentation for me to submit when appropriate.
I understand that I am responsible for submitting and participating in my appeal when requested, including completing forms, uploading documents, responding to my insurance company, or providing additional information.
In some circumstances, Billing for Littles may choose to submit or participate directly in an appeal on my behalf or on behalf of my Provider. Direct appeal submission or representation is not guaranteed and will be determined by Billing for Littles based on the circumstances of the claim.
Billing for Littles cannot guarantee the outcome of an appeal or that my insurance company will change its original determination.
C. No Guarantee of Coverage or Payment
I understand that Billing for Littles does not control my insurance company’s coverage or payment decisions and cannot guarantee:
That services will be covered;
How my insurance company will process a claim;
The amount my insurance company will allow or pay;
The amount that may be applied to my deductible, coinsurance, copayment, or other patient responsibility; or
The amount of reimbursement I may receive.
Billing for Littles is not responsible for changes in my insurance coverage, inaccurate information provided by my insurance company, claim denials or reductions, or processing decisions made by my insurance company.
D. Patient Responsibility for Monitoring Claims
I understand that my insurance company may send claim information, Explanation of Benefits (EOBs), requests for information, payments, or other correspondence directly to me. Billing for Littles may not receive copies of these communications or have access to all information available through my insurance company’s member portal.
I agree to monitor my insurance claims through my insurance company’s online member portal and/or statements I receive. I will contact Billing for Littles if:
I do not see expected claims appearing with my insurance company;
I receive an EOB, letter, request, denial, or other insurance communication that I would like Billing for Littles to review; or
I become aware of a claim issue that may require follow-up.
I understand that timely communication is important. If I receive insurance correspondence related to my midwifery claims, I am responsible for providing it to Billing for Littles when assistance or follow-up is needed.
6. PROVIDER FINANCIAL AGREEMENT & PATIENT RESPONSIBILITY
Billing for Littles provides billing services on behalf of my Provider but does not establish or modify my Provider’s fees, payment policies, or financial terms.
By signing this registration, I confirm that I have received, reviewed, and agreed to my Provider’s financial terms and understand my financial responsibilities to my Provider.
I understand that submitting claims to insurance does not replace or modify my agreement with my Provider. I remain responsible for amounts owed under that agreement, subject to applicable insurance requirements and law.
Gap or Network Exceptions: If my insurance company approves a gap exception, network exception, or similar arrangement for my care, I understand that this does not make my Provider an in-network or contracted provider. It only affects how my insurance company processes eligible claims under the terms of the exception.
Insurance Overpayments & Recoupments: I understand that insurance payments may later be adjusted, reversed, or recouped by my insurance company. If my Provider has refunded or forwarded insurance funds to me and the insurance company later requires my Provider to return those funds, I agree to repay the affected amount to my Provider, to the extent I received or benefited from those funds.
Questions regarding my Provider’s fees, payment arrangements, refunds, or amounts due should be addressed directly with my Provider.
7. ACKNOWLEDGMENT & AGREEMENT
By signing below, I confirm that I have read and understand this agreement and agree to the terms of the Billing for Littles insurance billing service.
I authorize Billing for Littles, the maternity services division of Lyons Medical Billing, to provide billing services on behalf of my Provider and to communicate with my Provider and insurance company as necessary to perform those services.
I have read and agree to the terms above.