TARAL SHARMA, MD, PC

120 PELHAM LN

Phone: (864) 844 – 9432

Fax: (864) 844-9430

Non-covered services agreement:

Introduction:

Like many new procedures, it will be difficult or impossible to get reimbursement for Esketamine administration codes. Insurance reimbursement for our more traditional services will be similar for Taral Sharma, MD, PC as for other providers you may have used. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis. Sometimes we have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). We will provide you with a copy of any report we submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for services yourself to avoid the problems described above unless prohibited by contract.

Agreement:

I,

being a patient of Taral Sharma, MD, PC, located at 120 Pelham Lane, Anderson, SC 29621, do hereby acknowledge that it has been explained to me the following services are not or may not be covered by the benefits available to me under the terms of my health plan or insurance policy:

  • HCPCS code: J3490 - Unclassified drugs
  • CPT Codes (90791-90792)
  • CPT Codes (90833-90837)
  • CPT Codes (99201-99205)
  • CPT Codes (99212-99215)
  • CPT Codes (99415, 99416)
  • CPT Codes (90867, 90868, 90869)
  • CPT Codes (99358, 99359)
  • CPT Codes (G2082, G2083)
  • Any other CPT Codes or Procedures

I understand that my health insurance coverage has certain restrictions and limitations, such as authorization requirements, and non-covered services and supplies. Some services may be determined to be not medically necessary, investigational, or not eligible because they are newer treatment modalities, maintenance, prevention or wellness care in nature.

I acknowledge that I have been told, in advance of treatment, what portion of my care is considered not covered by my health plan or insurance policy, and I agree to make financial arrangement with my practitioner to pay for these services.

Patient Signature:
Patient’s Printed Name:
Dated:
Health Plan / Insurance Policy:
Member ID Number:
Date of Birth: