ࡱ> .0- #bjbj 1ee 6 6 8D$XX0HhM:0D(D6 V:  Patient Notification for Payer Payment Policies for Certain In-Office Procedures The һϲ - Head and Neck Surgery has drafted a template letter, which members may use to notify patients of additional payments for certain diagnostic procedures performed during office-visits for which they may be financially responsible. This letter is generic and acts only as guidance for you to construct your notification; you should edit the list of procedures to reflect the specific procedures you performed on your patient on the stated date of service. Please use your company letterhead/logo as well as fill in the blanks. Contact the Health policy department at  HYPERLINK "mailto:Healthpolicy@entnet.org" Healthpolicy@entnet.org if you have any questions on this letter. Patient Name: ___________________________________ Please be aware that certain procedures performed inour office are not included in the standard office visit. These procedures will be billed separately and in addition to office visit charges. We have become aware that some insurance carriers are classifying these procedures as "Surgery" and applying the charges to a higher deductible amount. The result may be insurance payment for an office visit but not a procedure. In such cases, payment for the procedure will be due from the patient. Be assured that we are following accepted billing and coding guidelines and that all procedures are performed in the best interest of patient care. Examples of in-office procedures include: Flexible laryngoscopy: This procedure involves passing a long thin flexible fiberoptic scope through the nasal cavity and into the throat. The fiber optic scope enables the physician to visualize areas of the throat not readily seen using the laryngeal mirrors. Nasal endoscopy: This procedure uses the flexible or rigid scope attached to a light source to view areas of the nasal cavities that cannot be viewed by the physician using the standard nasal speculum and head mirror. Nasal endoscopy with debridement or biopsy: This is the same procedure as above with removal of crusting or tissue. Please speak with our nurse or clinical assistants if you have any questions. ___________________________ _________________ Patient Signature Date     RW` < H T ? ! # ݵxeXPjh9dvUh,^khACJOJQJ%h,^khAB*CJOJQJaJph#hzh,^k0J6CJOJPJQJ1jhzh,^k6B*CJOJPJQJUph"h,^k6B*CJOJPJQJph(hzh,^k6B*CJOJPJQJph%h,^k5>*B*CJOJQJaJph+hzh,^k5>*B*CJOJQJaJphhAB*CJaJphRS! " # V W oqs$a$gd,^kgd,^k !"#gdA "#h,^khACJOJQJjh9dvUh9dv/1h;0/ =!"#$% ^ 666666666vvvvvvvvv66666686666666666666666666666666666666666666666666666666hH666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH H`H Normal*$CJPJ_HaJmH sH tHDA`D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List J/J Absatz-StandardschriftartDA`D Default Paragraph FontNN Balloon Text CharCJOJQJ^JaJ6!6 Header CharCJaJ616 Footer CharCJaJNORN Heading x$CJOJPJQJ^JaJ6B@R6  Body Text x(/@Qb( List^JH"@rH Caption xx $6CJ]^JaJ.O. Index $^J@^@@ Normal (Web) PJ^JaJH@H Balloon TextCJOJQJ^JaJ44 Header  H$4 4 Footer  H$6U@6 ,^k0 Hyperlink >*B*phPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] #  # # # X8@0(  B S  ?\f          $        $ A,^knhl9dv  @# @UnknownG* Times New Roman5Symbol3. * Arial7.@Calibri5. .[`)TahomaG=  jMS Mincho-3 fgA$BCambria MathBh4'4'J&[[!r0  3QHP $P,^k!xx YMBDecrescenzo, RebeccaOh+'0<x   $,4YMB Normal.dotmDecrescenzo, Rebecca2Microsoft Office Word@@dɠ@ P@ P[՜.+,D՜.+,0 hp  һϲ   Title 8@ _PID_HLINKSAx|\mailto:Healthpolicy@entnet.org  !"#$&'()*+,/Root Entry Fph11TableWordDocument1SummaryInformation(DocumentSummaryInformation8%CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q