Insurance Info

Below is the list of current insurance companies Longview Orthopedic Associates is contracted with. Please contact your insurance company for further information as it is the patient’s or guardian’s responsibility to know their insurance benefits, coverage and if they are being treated at an office in network with their insurance plan.

• AARP
• Aetna (Commercial and Medicare)
• Care Oregon
• Cigna (Commercial and Medicare)
• Coordinated Care
• Dept. of Labor and Industries
• DSHS (WA Medicaid)
• First Choice
• Heath Net (Commercial and Medicare)
• HMA
• Humana (Commercial and Medicare)
• Kaiser Permanente
• Lifewise
• Medicare and Railroad Medicare
• Moda (Connexus Network)
  • NOT Synergy Network
  • NOT Beacon Network
• Molina
• OMAP (Oregon Medicaid)
• Pacific Source (NOT the Legacy Health Network)
• Premera Blue Cross
• Providence (Commercial and Medicare)
• Regence Blue Cross Blue Shield
• Tricare
• TriWest
• UMR
• US Dept. of Labor
• United Healthcare (Commercial, Medicare, and Community Care)
• Worker’s Comp. (Self-funded and L&I)
• And other Misc. Insurances

Model Disclosure Notice Regarding Patient Protections Against Surprise Billing

Instructions for Providers and Facilities

(For use beginning January 1, 2022)

Section 2799B-3 of the Public Health Service Act (PHS Act) requires health care providers and facilities to make publicly available, post on a public website of the provider or facility (if applicable), and provide a one-page notice that includes information in clear and understandable language on:

1. the restrictions on providers and facilities regarding balance billing in certain circumstances,
2. any applicable state law protections against balance billing, and
3. information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.

Health care providers and facilities may, but aren’t required to, use this model notice to meet these disclosure requirements. To use this document properly, the provider or facility should review and complete it in a manner consistent with applicable state and federal law. HHS considers use of this model notice in accordance with these instructions to be good faith compliance with the disclosure requirements of section 2799B-3 of the PHS Act and 45 CFR 149.430, if all other applicable PHS Act requirements are met.

If a state develops model language for its disclosure notice that is consistent with section 2799B-3 of the PHS Act, HHS will consider a provider or facility that makes good faith use of the state-developed model language to be compliant with the federal requirement to include information about state law protections.

Public Disclosure Requirements

The disclosure notice must be publicly available, and (if applicable) posted on a provider’s or facility’s public website.

• To satisfy the public disclosure requirement, providers and facilities must prominently display a sign with the required disclosure information in a location of the provider or facility, such as, where individuals schedule care, check-in for appointments, or pay bills, unless the provider doesn’t have a publicly accessible location.
• To satisfy the separate requirement to post the disclosure on a public website, the disclosure or a link to the disclosure must appear on a searchable homepage of the provider’s or facility’s public website.

Who should get this notice

In general, providers and facilities must give the disclosure notice to individuals who are participants, beneficiaries, or enrollees of a group health plan or group or individual health insurance coverage offered by a health insurance issuer, including covered individuals in a health benefits plan under the Federal Employees Health Benefits Program, and to whom they furnish items or services, and then only if such items or services are furnished at a health care facility, or in connection with a visit at a health care facility.

Provision of the notice

Providers and facilities must provide the notice in-person, by mail, or via email, as selected by the individual. The disclosure notice must be limited to one-page (double-sided) and must use a font size of 12-points or larger.

Providers and facilities must issue the disclosure notice no later than the date and time on which they request payment from the individual (including requests for copayment or coinsurance made at the time of a visit to the provider or facility). If the provideror facility doesn’t request payment from the individual, the notice must be provided no later than the date on which the provider or facility submits a claim for payment to the plan or issuer.

Language access

Use of Plain Language

Health care providers, facilities, plans, and issuers are encouraged to use plain language in the disclosure notice and test the notice for clarity and usability when possible.

Plain language, accessibility, and language access resources:

• Plainlanguage.gov/guidelines
• Section508.gov
• LEP.gov

Compliance with Federal Civil Rights Laws

Entities that receive federal financial assistance must comply with federal civil rights laws that prohibit discrimination. These laws include section 1557 of the Affordable Care Act, Title VI of the Civil Rights Act of 1964, and section 504 of the Rehabilitation Act of 1973. Section 1557 and title VI require covered entities to take reasonable steps to ensure meaningful access to individuals with limited English proficiency, which may include offering language assistance services such as translation of written content into languages other than English.

Section 1557 and section 504 require covered entities to take appropriate steps to ensure effective communication with individuals with disabilities, including provision of appropriate auxiliary aids and services. Auxiliary aids and services may include interpreters, large print materials, accessible information and communication technology, open and closed captioning, and other aids or services for persons who are blind or have low vision, or who are deaf or hard of hearing. Information provided through information and communication technology also must be accessible to individuals with disabilities, unless certain exceptions apply. Providers and facilities are reminded that the disclosure notice must comply with applicable state or federal language-access standards.

NOTE: The information provided in these instructions is intended to be only a general summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance on which it is based. Refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.

Do not include these instructions with the disclosure notice provided to patients.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average 3.5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland 21244-1850.

Instructions for Group Health Plans and Health Insurance Issuers

(For use for plan years beginning on or after January 1, 2022)

Federal law requires group health plans and health insurance issuers offering group or individual health insurance coverage to make publicly available, post on a public website of the plan or issuer, and include on each explanation of benefits for an item or service with respect to which the requirements under section 9816 of the Internal Revenue Code (the Code), section 716 of the Employee Retirement Income Security Act (ERISA), and section 2799A-1 of the Public Health Service Act (PHS Act) apply, information in plain language on:

1. the restrictions on balance billing in certain circumstances,
2. any applicable state law protections against balance billing,
3. the requirements under Code section 9816, ERISA section 716, and PHS Act section 2799A-1, and
4. information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.¹

Plans and issuers may, but aren’t required to, use this model notice to meet these disclosure requirements. To use this document properly, the plan or issuershould review and complete it in a manner consistent with applicable state and federal law. The Departments of Health and Human Services, Labor, and the Treasury (the Departments) will consider use of this model notice in accordance with these instructions to be good faith compliance with the disclosure requirements of section 9820(c) of the Code, section 720(c) of ERISA, and section 2799A-5(c) of the PHS Act, if all other applicable requirements are met.

If a state develops model language for its disclosure notice that is consistent with section 9820(c) of the Code, section 720(c) of ERISA, and section 2799A-5(c) of the PHS Act, the Departments will consider a plan or issuer that makes good faith use of the state-developed model language to be compliant with the federal requirement to include information about state law protections.

Language access

Use of Plain Language

Plans and issuers are encouraged to use plain language in the disclosure notice and test the notice for clarity and usability when possible.

Plain language, accessibility, and language access resources:

¹ Section 9820(c) of the Code, section 720(c) of ERISA, and section 2799A-5(c) of the PHS Act.

• Plainlanguage.gov/guidelines
• Section508.gov
• LEP.gov

Compliance with Federal Civil Rights Laws

Entities that receive federal financial assistance must comply with federal civil rights laws that prohibit discrimination. These laws include section 1557 of the Affordable Care Act, Title VI of the Civil Rights Act of 1964, and section 504 of the Rehabilitation Act of 1973. Section 1557 and title VI require covered entities to take reasonable steps to ensure meaningful access to individuals with limited English proficiency, which may include offering language assistance services such as translation of written content into languages other than English.

Section 1557 and section 504 require covered entities to take appropriate steps to ensure effective communication with individuals with disabilities, including provision of appropriate auxiliary aids and services. Auxiliary aids and services may include interpreters, large print materials, accessible information and communication technology, open and closed captioning, and other aids or services for persons who are blind or have low vision, or who are deaf or hard of hearing. Information provided through information and communication technology also must be accessible to individuals with disabilities, unless certain exceptions apply. Plans and issuers are reminded that the disclosure notice must comply with applicable state or federal language-access standards.

NOTE: The information provided in these instructions is intended to be only a general summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance on which it is based. Refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.

Do not include these instructions with the disclosure notice provided to participants, beneficiaries, or enrollees.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1401. The time required to complete this information collection is estimated to average 3.5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland 21244-1850.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center (not a clinical setting), you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. This does not apply to: Medicare, Medicaid, Tricare, and TriWest as they are public plans.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact HHS at 202-690-6343 or visit www.cms.gov/nosurprises for more information.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intendedonly to provide clarity to the public regarding existing requirements under the law.

Medicaid

Longview Orthopedic Associates requires a referral to be seen in our office as well as verified active insurance coverage at each visit. If we cannot confirm eligibility at the time of the appointment, you will be considered "Self Pay" and expected to bring a $100 deposit to your appointment and at that time meet with our billing department to discuss a payment plan. If you become eligible and or reinstated for that date of service we will then bill your insurance and refund you the amount you have paid out of pocket.

THIRD PARTY CLAIMS: Longview Orthopedic Associates does not bill third party claims.

HMO PLANS: A referral is required from your primary care physician prior to each appointment and procedure. If we do not have a referral at the time of the appointment, you will be asked to reschedule or sign a waiver stating you will be responsible for all charges incurred during your visit.

WORKERS’ COMPENSATION: It is your responsibility to inform Longview Orthopedic Associates that the visit is for a work-related injury and will also need to provide your date of injury, employer name, claim number, claims manger's name, phone number and fax number. This is to your benefit so that we can get you treated in a timely manner and bill appropriately. If the claim is DENIED or CLOSED or if you fail to inform Longview Orthopedic Associates of the work-related nature of your medical problem, including appropriate claim information, you will be responsible for all charges.

PRIVATE PAY: Please see self pay requirements below and contact billing department prior to your visit in order to establish a payment agreement. Longview Orthopedic Associates can also give you information on Care Credit to help with payments for your medical services, please contact us for more information.

• A $100 deposit is required prior to the New Visit to Longview Orthopedic Associates if you pay by cash, check, or credit/ debit card.
• Longview Orthopedic Associates makes every effort to include all visit-related charges by the end of the visit for private pay patients. However, the charges are an estimate, and you may receive a bill for any remaining charges by statement.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical services or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more that your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate

For questions or more information about your right to a Good Faith Estimate, contact our billing office at 360-501-3400. You can also obtain additional information at www.cms.gov/nosurprises

Disclaimer

The Good Faith Estimate shows the cost of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknow or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You many contact the healthcare provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate, ask to negotiate the bill, or ask to set up a payment plan.

You may also start a dispute resolution process with the U.S Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

If you have questions regarding this Good Faith Estimate or bill, contact our billing department at 360-501-3400. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS 202-690-6343.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call HHS 202-690-6343.

Keep a copy of your Good Faith Estimate in a safe place or take a picture of it.

CO-PAY: Copayment is due at the time of service.

• Co-Pay: A flat rate applied to office visits and/or procedures pre determined by your health plan.

DEDUCTIBLE & COINSURANCE: You will receive a monthly statement showing itemized charges and the current amount due on your account. Payment in full is required within 60 days of the date on your statement. If you are unable to make payment in full within the 60-day period, you must notify the Longview Orthopedic Associates Business Office and make payment arrangements or utilize the Care Credit plan if you are unable to make the payment due in full.  Each statement will detail this information as well as the payment plan options. 

• Deductible: The amount you must pay for services out of pocket to your provider before your insurance will begin to pay for your claims. This is outlined in your insurance plan.
• Coinsurance: A percentage amount for which you are responsible for per visit or procedure. This is also outlined in your insurance plan.

AUTHORIZATION: Longview Orthopedic Associates will make every effort to pre-authorize services. However, in the event that prior authorization is not received, you will be responsible for the charges. It is the patient’s or guardian’s responsibility to know the benefit coverage, as well as to make sure there is a prior authorization in place prior to receiving care if needed.

REFERRALS: Longview Orthopedic Associates requires a referral from your primary care physician for certain insurance plans. However, in the event that a referral is not received and the insurance requires it, or you have not established care with your PCP, you will be responsible for the charges. It is the patient’s or guardian’s responsibility to know their benefit coverage, as well as to make sure there is a referral in place prior to receiving care. If you have a coinsurance and/or a deductible balance as determined by your insurance plan, Longview Orthopedic Associates will send you a statement after your claim has been processed with the insurance. You are required to pay this balance in full to Longview Orthopedic Associates.

DURABLE MEDICAL EQUIPMENT: Medical products may be recommended and/or dispensed to assist you with the healing process. In some instances, you will be required to pay at the time of your visit for non-covered DME. For insurance covered items, Longview Orthopedic Associates will bill your insurance as a courtesy; however, you will be responsible to pay for any amount not covered by your insurance. Some items may be billed through an external DME company.

SURGERY:In the event you require surgery or a procedure, our office will work diligently to get a pre-authorization prior to scheduling. A cost estimate is available upon request. In the event you undergo a surgery or procedure at a facility other than Longview Orthopedic Associates, you will be responsible for three separate billings. One from the facility where the procedure took place. The second, from the anesthesiologist that provided anesthesia during your procedure. The third would be from our Physician at (Longview Orthopedic Associates) for performing the procedure. Most surgeries include a 10, 60, or 90-day global period, meaning the related post-operative visit(s) will not be billed, as it is included in the global package. Anything additional will be billed to the insurance company and applied to your benefits at that time of service. (X-rays, Casting, DME,  injections, ect.)

RADIOLOGY: In the event you require an MRI, you may be responsible for two separate bills, one from the facility where the MRI took place, and the second from the radiologist that provided the interpretation of the MRI.

FORM COMPLETION: If you require a form be completed by your provider, a $15 fee will be due at the time the form is submitted to our office. Form completion turn around time is 7–10 business days.

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