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ROCKCLIFF PLACE FINANCIAL POLICIES
Drs. Scully, Matheson, Fonseca, and Parworth
5 Rockcliff Place, Asheville, NC 28801
(828) 255-7781
1. Consult evaluations are required to be paid in full at the time of service, regardless of
insurance coverage. We will file your claim as a courtesy, and if we are reimbursed for
that visit, we will refund you any credit amount, or hold the credit amount to apply
toward your surgical fee.
2. Our practice does not participate with any insurance company. This means that we
do not have a signed contract or agreement with any insurance company, and any non-
covered services or remaining balance not paid by the insurance is ultimately the
patient’s responsibility.
3. Since we do not participate, some insurance companies will not reimburse our practice
and pay the patient directly for covered services. Blue Cross/Blue Shield (BCBS) and
Delta Dental are the two main companies that pay the patient directly. If you have one of
these insurances, you will be responsible for paying for any services rendered, in full, at
the time of service. Because we are not a participating provider with BCBS, you will be
responsible for filing your own claim. We will provide you with any necessary
procedure and diagnosis codes for you to complete your claim form.
4. If you have an insurance that will reimburse the provider, we ask that you pay a 30% to
70% deposit for any procedures. The deposit will be dependent upon your insurance
policy’s annual deductible, and yearly maximum allowable. We will file your claim, and
any remaining balance not covered by your insurance company within 90 days, will be
your responsibility. IF your insurance pays more than we estimate, we will refund you
any credit amount.
5. It has been our experience that most BCBS and United Health Care medical policies do
not cover removal of teeth. Also, many Cigna dental policies do not cover IV sedation,
therefore, it will be due at the time of surgery.
6. WE DO NOT ACCEPT MEDICARE, MEDICAID, NC HEALTH CHOICE, OR
ANY FORM OF MILITARY INSURANCE. Since we do not participate with
Medicare or Medicaid, you legally cannot file a claim on your own, and are considered a
“self-pay” patient.
7. Orthognathic services are not covered by dental insurance. Orthognathic patients with
medical insurance must pay for non-covered services and procedures, and are responsible
for at least 30% of their covered procedure before their surgery date. If you have BCBS,
you must pay for all orthognathic procedures in full before your surgery date. We will
file the surgery claim, and BCBS will reimburse you for the amount that is covered by
your plan.
8. BCBS will not do pre-determination of benefits on most procedures we perform, except orthognathic surgery.
9. Dental implants and bone grafts are usually not covered by insurance, however, extractions in preparation for implants may be covered. A pre-determination of benefits may be appropriate for these procedures. We require that all dental implants be paid in full at the time of service.
*By signing this, you acknowledge that you have read and understand the above
statements.
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Patient or legal guardian Date
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