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Estimate of Costs form - E-Signature

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Dear

As a courtesy, the billing department of MN CarePartner/Roots Recovery has called your insurance company to verify your coverage and estimated out-of-pocket costs. It is important to remember that the responsibility of knowing your coverage and obligations remain yours and we can only provide an estimate of what you should expect to pay out of pocket.

Below is an Estimated Explanation of Costs for you:

Per your insurance, you will have a Co-Pay of $ for each visit, which is due at the time of service. If you are being seen via telehealth or In-Home, you have the following options:

A. Contact the billing department of MN CarePartner immediately before or after your virtual/In-home visit to make a payment for your assigned Co-Pay.

Phone: 612.289-5656

email: billing@mncarepartner.com

B.Go onto the MN CarePartner website, https://mncarepartner.com, Click on “Paying for Services” then click on “Make a Payment” and from there, follow the prompts to make a payment in the amount of your copay. That payment will come directly to the billing department, and we will mail you out a receipt once payment has been posted to your account.

If you are seen in office, you will be expected to make a payment with the Office Manager, Director of Operations or have someone in the office contact the billing department to take your payment for your visit.
If neither of these options are chosen, the next business day following your appointment, our billing department will run your credit card on file for the visit Co-Pay and email/mail you are receipt for your payment.

Per your insurance, you have a Deductible of $ and have only met $ . Once your deductible is met, your claims will be paid at % leaving you with a responsibility of % to pay. Based off the services you are requesting, your estimated out of pocket cost for each visit will be $ . If you are being seen via telehealth or In-Home, you have the following options:

A. Contact the billing department of MN CarePartner immediately before or after your virtual/In-home visit to make a payment for your estimated deductible payment. Phone: 612.289-5656

email: billing@mncarepartner.com

B. Go onto the MN CarePartner website, https://mncarepartner.com, Click on “Paying for Services” then click on “Make a Payment” and from there, follow the prompts to make a payment in the amount of your deductible. That payment will come directly to the billing department, and we will mail you out a receipt once payment has been posted to your account.

If you are seen in office, you will be expected to make a payment with the Office Manager, Director of Operations or have someone in the office contact the billing department to take your payment for your visit.
If neither of these options are chosen, the next business day following your appointment, our billing department will run your credit card on file for the visit Deductible and email/mail you are receipt for your payment.

Please remember that these are only estimates of charges and may increase or decrease once claims are processed by your insurance company.

MN CarePartner/Roots Recovery offer very flexible payment arrangement options if your out of pocket costs are outside of your immediate budget. Please reach out to someone in the billing department to discuss those options.

If you have further questions regarding the information obtained from your insurance company, we encourage you to reach out directly to the telephone number on the back of the card. You are also welcomed to contact the MN CarePartner/Roots Recovery Billing Department via:

Telephone: 651-289-5656 *Press Option 3

Email: Billing@mncarepartner.com

We are here to support you in your journey of Health and Wellness. Please don’t hesitate to reach out with any questions!

Commonly Used Billing/Insurance Terms:

Co-Pay: A fixed amount ($20, for example) you pay for a covered health care service. Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20. Copayments (sometimes called "copays") can vary for different services within the same plan, like meds, lab tests, and visits to specialists.

Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services.

Co-Insurance: The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.

If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
If you haven't met your deductible: You pay the full allowed amount, $100.

Out of Pocket Max: The most you must pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit doesn't include: Your monthly premiums.

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February 10, 2022 3:48 am CDT

Estimate of Costs form - E-Signature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.190.44