Insurance contractual discounts are not affected by the Payment Assurance Discount as this discount applies only to the patient out of pocket expense after any insurance claims have been processed.
The Valley Health 15% Employee Discount shall be applied after adjudication of all claims by all insurance coverages on the account to the final explanation of benefits (EOB) patient responsibility amount transferred to the Self-Pay liability bucket on all accounts on which the current Valley Health employee insurance coverage is active and adjudicated a claim that resulted in a Patient Responsibility amount for any reason other than lack of patient eligibility or any other denial resulting from a patient’s lack of compliance with the provisions of their insurance contract. Valley Health employees and their dependents who are eligible for the Employee Discount but not covered by the Valley Health insurance plan must manually request the Employee Discount as a mechanism does not currently exist in Epic to reliably identify employees and their covered dependents. In cases in which the patient out of pocket expense after insurance and/or after application of the Employee Discount, if applicable, is less than $500.00 per covered CT, MRA, or MRI, the Payment Assurance Discount shall not be used, regardless of whether the patient paid $500.00 per covered CT, MRA, or MRI. In such cases, the patient will be given credit for the Pre-Payment Discount, calculated as 11.1111% of the pre-paid amount.
The Payment Assurance Discount shall not be used in combination with other Valley Health patient Pre- Payment or Prompt-Payment discounts; however, the patient discount structure that provides the lowest out of pocket expense to the patient for the covered services shall be applied. Thus, if another combination of discounts for which the patient would otherwise be eligible results in a lower patient out of pocket, than that combination of discounts shall be used in place of the Payment Assurance Discount. For the purposes of determining eligibility for the Payment Assurance Discount and Pre-Payment Discount, any monies to be applied to these discounts will first be applied to the covered CT’s and MRI’s and any remaining pre-paid amount shall receive a proportional 10% Pre-Payment Discount credit.
The Payment Assurance Discount has no effect on the Valley Health Financial Assistance Program.
Patient Estimates: Patient out of pocket estimates are based on the best information available at the time the estimate is prepared and the final patient out of pocket liability after services have been performed and all claims have been adjudicated by all eligible insurers may ultimately be greater or less than the original estimate.
In the event that the Payment Assurance Discount is originally believed to be applicable based upon an estimate but the patient out of pocket responsibility after insurance adjudication is ultimately less than $500 per CT, MRI, or MRA, then the Payment Assurance Discount shall not be applied and the patient shall be given credit for a Pre-Payment Discount at 11.1111% of the amount pre-paid, if such discount has not already been taken. Any resulting credit balances will be processed as indicated below under “Discounts resulting in a Credit Balance”. In the event that the patient out of pocket liability is ultimately greater than the estimate, the Payment Assurance Discount will continue to apply, capping the patient liability for covered CT’s, MRA’s, or MRI’s at $500 per covered procedure as indicated by the final insurance explanation of benefits. Any remaining out of pocket liability for non-covered services shall be billed to the patient if the overall account balance is $10.00 or more.
In the event that the original out of pocket estimate materially under-estimated the patient’s out of pocket liability to the degree that the original estimate indicated that the patient would not be eligible for the Payment Assurance Discount because the expected out of pocket would be less than $500 per covered CT, MRI, or MRA and, after final claims adjudications, the ultimate patient out of pocket is greater than $500 per covered CT, MRI, or MRA, then the patient will be given 30 days from the date of the first statement to take advantage of the Payment Assurance Discount; however, in order to be retro-actively eligible: (1) The estimate must be documented, (2) payment of at least $500 per CT, MRA, or MRI must be received within 30 days of the date of the first statement before such discounts will be applied, and (3) the patient must notify Valley Health of their intention to take advantage of the program within the 30 day window. Discounts resulting in a Credit Balance: Small Balance Credits: In the event that application of the Payment Assurance Discount, Pre-Payment Discount, or any other patient discount results in a credit balance between $ -0.01 and $ -9.99, the contributing discount shall be reversed up to the amount of the credit balance in order to create an overall account balance of $0.00, provided the reversal is not greater than the original amount of the discount. Credit Balances in Excess of $ -9.99: In the event that application of the Payment Assurance or Pre- Payment Discount in conjunction with a patient payment results in a credit balance in excess of $ -9.99, then the patient payment and any patient discounts shall each be partially reversed at a pro-rata level to create an overall account balance of $0.00 and the amount of patient payment that is reversed shall be refunded to the patient or applied to any other amounts owed by the patient or guarantor in accordance with the Valley Health refund policy.