Insurance and billing
I ask PNW Wound Specialist, LLC to bill my insurance for services provided. PNW may use and disclose information for billing and care coordination as permitted by law. I will provide current insurance information and tell PNW about changes.
Benefit checks, referrals, and prior authorizations do not guarantee payment. Coverage depends on my plan and its rules.
Amounts I may owe
I am responsible only for amounts that PNW may lawfully bill me under applicable law and payer contracts. These may include permitted deductibles, copayments, and coinsurance after insurance and any secondary coverage are processed. For covered services, PNW accepts the applicable contracted or Medicare allowed amount.
A denial, missing authorization, billing error, or later audit does not automatically make a charge my responsibility. PNW will review the reason, applicable protections, and required notices before billing me. This agreement does not transfer charges that remain the provider's responsibility.
Medicare and Apple Health protections
Qualified Medicare Beneficiary (QMB): Patients with QMB protection do not owe Medicare deductibles, copayments, or coinsurance for Medicare-covered services, even if Medicaid or another payer does not pay those amounts.
Washington Apple Health: PNW follows Washington's limits on billing Medicaid patients. This general agreement does not replace HCA Form 13-879, Agreement to Pay for Healthcare Services, when that form and its requirements apply.
Services insurance may not cover
Before a service expected not to be covered, our team will explain the service, the reason coverage may be denied, covered alternatives when applicable, and an estimated cost. Any required service-specific notice or agreement will be completed before treatment.
For Original Medicare, an Advance Beneficiary Notice of Noncoverage (ABN) will be provided when required. An Original Medicare ABN is not used for Medicare Advantage services; the applicable plan process will be followed. Signing this general form is not signing an ABN or agreeing to every noncovered service.
Outside laboratories, suppliers, and other providers may bill separately. Their charges and coverage should be discussed with those organizations.
Self-pay and payment questions
If I am uninsured or choose self-pay where permitted, PNW will discuss charges before care and provide a Good Faith Estimate when required. I may request an estimate.
I agree to pay a lawful patient balance within 30 days after receiving a statement, or contact PNW to discuss the bill or payment arrangements. I may ask for an itemized explanation or dispute a charge without giving up my insurance appeal rights.
Questions: 509-209-9033 or info@pnwwoundspecialist.com. Please do not send Social Security numbers or other sensitive identifiers by ordinary email.
Acknowledgment
I have had an opportunity to ask questions. I understand that this agreement does not waive my legal protections or authorize charges prohibited by law or payer contracts. A representative signing for the patient does not personally guarantee payment solely by signing as a representative.