Non Covered Services Policy

15204 Omega Drive

Suite #100 Rockville, MD 20850

2025 Non Covered Services Fee - Primary Care

Service	NCSF Package	A La Carte
Health (school/camp) forms*	Included	$50 per form packet
Patient letters of medical necessity/clearance/advocacy	Included	$75 per form
Prior authorizations (excluding appeals, see pricing below)	Included	$50 per call
Insurance claim appeals	Included	$25 per appeal
Prescription refills	Included	$20 per medication per refill
After hours calls to answering service	Included	$30 per call
Medical Records	Included	$50 per file
Billing summaries **	Included	$5 per page
Account resolution with company HR and insurance	Included	$25 per 30 minutes
Immunization Record***	Included	$15 per request

*Prior Authorization Appeals: All prior authorization appeals will incur a $100 charge due to the amount of time both the provider and nurse must spend with your insurance company to get your preferred medication approved.
*Many children need 2 or more per year
**Billing summaries are often required for FSA/Tax/Legal and other personal purposes.
***Immunization records are available on the portal, included with all health form packets, and can be printed at your well check free of charge. This fee applies for official Maryland form request outside of these parameters.

Please note that opt out period for March 2025 Annual NCSF has expired and request for late waivers will not be granted. Patients who opt out must do so each year! Due to the complexity of billing for both bundled and a la carte service option, those who choose to opt out of this fee are not eligible to opt into the bundled services until the following NCSF year. NCSF charges for families who have not opted out will begin March 1, 2025, and will be charged under the oldest child for the family.

2025 Non-Covered Services Fee - Mental Health

Therapy & Psychiatry Services

The needs of families who are accessing our mental health department are significantly more than those only utilizing primary care services and therefore the following ADDITIONAL pricing and opportunity to pre-purchase bundled services applies.

Pricing

Psychiatry Package per Child- $275
Therapy Package per Child- We have eliminated the NCSF for therapy the 2025. A la carte pricing will apply.

Service	Package	A la carte
Health forms	Included	$50 per form packet
Patient letters of medical necessity/clearance/advocacy	Included	$150 per letter
Prior authorizations (excluding appeals, see pricing below)	Included	$50 per episode
Prior authorizations with a peer-to-peer communication	Included	$250 per episode
Peer-to-peer collaboration (with another provider, therapist, school counselor, caretaker)	Included	$125 per episode (Therapist) $250 per episode (Psychiatrist)
Prescription refills without an office visit	Included	$50.00 per medication per refill

Videos Explaining Non-covered Services

Potomac Pediatrics will always be fully focused on helping your child and you to overcome any healthcare hurdle, with innovative, comprehensive and compassionate care.

Questions?

301-279-6750

15204 Omega Drive