2016 Practice Information Disclosure Sheet For Patients and Prospective Patients

Transcription

1 2016 Practice Information Disclosure Sheet For Patients and Prospective Patients New York State requires medical practices to disclose to current and prospective patients information regarding health plan participation, hospital affiliations, referral providers, and the availability of charge data for non-emergency out of network services, if applicable. Below is the required information, which is available on our web site at or via hard copy if needed. Nephrology Associates of Syracuse, PC is a provider for Medicare and most major insurance plans. Questions regarding insurance coverage and benefits should be directed to your insurance company. If you have questions regarding billing or which insurance plans we accept, please call our Billing Office at Health Insurance Plan Participation Government Programs: Medicare Medicaid Health Care Exchange Plans: CDPHP Fidelis MVP Medicaid Managed Care Options: Fidelis Total Care United Healthcare, including the United Healthcare Dual Complete Community Plan Medicare Managed Care Plans: Aetna MVP Today s Options WellCare United Healthcare including the United Healthcare Dual Complete Community Plan 1

2 PPO and HMO Plans: Aetna CDPHP CIGNA Emblem Health/GHI Empire Plan - UHC Humana Martin s Point and USA Family MultiPlan/PHCS MVP POMCO If your health plan is not listed on page one or above, please call your insurance company directly. List of additional Medicare Supplemental Plans that often act as a secondary payor: AARP- Medicare Supplemental Insurance Plan via United Healthcare Mutual of Omaha Medicare Supplement Insurance NALC National Association of Letter Carriers Tricare for Life Tricare North Hospital Affiliations Crouse Hospital 736 Irving Avenue St. Joseph s Hospital Health Center 301 Prospect Avenue Syracuse, NY

3 Disclosure Prior to Non-Emergency Services being Provided to Patients and Prospective Patients with insurance coverage from plans that we do NOT participate with: Patients and prospective patients with insurance coverage from plans that we do NOT participate with please be advised that before non-emergency services are provided, the amount you will be billed is available upon request. If you submit such a request, we will disclose in writing the amount or estimated amount that will be billed for services provided or anticipated to be provided, absent unforeseen medical circumstances that may arise when services are provided. Please note that as many insurance contracts contain provisions do not permit the sharing of contracted rates, we will disclose our charges. Please note that the amount a patient and/or his/her insurance company pay will generally be less than charges, and those rates apply even if you, as a patient, have not yet met your deductible. Please call the Customer Service Department of your insurance company if you have any questions related to participating providers in your health plan. Laboratory Services Nephrology Associates of Syracuse, PC offers in-house laboratory services. There are some lab tests which are not able to be performed here and these are sent directly to Lab Alliance, our reference laboratory. There are some insurance plans which do not allow payment for select lab tests to be performed in a physician office setting, and thus, these lab tests must be sent outside to Lab Alliance in order for lab tests to be covered. It is your responsibility to contact your insurance plan for specific coverage questions. 3

4 Referral Providers On occasion, your provider may refer you to another provider, or may recommend that you have additional tests or services. Below is a list of providers that you may be referred to along with their address and contact information. Prior to having services rendered, it is your responsibility to contact your insurance plan or these referral providers directly, to confirm that they participate with your insurance plan. Please note that unforeseen medical issues may arise which may necessitate referring you to another provider that is not listed below, based on your individual medical condition. We have listed the main location for each provider group and would encourage you to contact them directly to determine the most convenient location for your individual needs. Arthritis Health Associates Rheumatology 310 South Crouse Avenue Associated Gastroenterologists Gastroenterology 4870 Broad Road, Suite 3Q Syracuse, NY Associated Medical Professionals of NY, PLLC Urology 1226 East Water Street Crouse Medical Practice - Cardiology, PC Cardiology 739 Irving Avenue CNY Diagnostic Imaging Associates 4939 Brittonfield Parkway East Syracuse, NY

5 CNY Surgical Physicians Surgery 739 Irving Avenue Suite Crouse Radiology Associates 5008 Brittonfield Parkway East Syracuse, NY Hematology Oncology Associates Hematology and Oncology 5008 Brittonfield Parkway East Syracuse, NY I.A. Tangoren, MD, PLLC Dermatology 2949 Erie Boulevard East, Suite 110 Syracuse, NY Laboratory Alliance Lab Services with multiple sites 1304 Buckley Road Syracuse, NY Customer Service Northeast Vascular Imaging Group 1 Fallentree Lane Clifton Park, NY

6 Pulmonary Health Physicians, PC Pulmonology 945 East Genesee Street, Suite SJH Cardiology Associates Cardiology 4820 West Taft Road, Suite 209 Liverpool, NY St. Joseph s Imaging Associates 5100 West Taft Road Liverpool, NY Syracuse Orthopedic Associates Orthopedics 5719 Widewaters Parkway Syracuse, NY Upstate Medical University Transplant Surgery 750 East Adams Street Vascular Surgeons of CNY, PLLC Vascular Surgery 104 Union Avenue, Suite 1005 Syracuse, NY