Non Covered Services Policy

Non Covered Services Fee- Primary Care

Pricing

Individual- $90
Family Maximum- $200
A la carte option available

Service	NCSF Package	A La Carte
Health (school/camp) forms*	Included	$50 per form packet
Patient letters of medical necessity/clearance/ advocacy	Included	$50 per form
Prior authorizations	Included	$50 per call
Insurance claim and prior authorization appeals	Included	$25 per call
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	$10 per request

*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.

If you are electing to opt out of the NCSF for primary care and/or mental health services this year, please click the button below. You must complete this waiver for each child for whom you are waiving the bundled package. We must receive your opt out waiver no later than February 28, 2023 at 11:59pm. 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, 2023, and will be charged under the oldest child for the family.

Mental Health Non-Covered Services Fee

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- $200
- Therapy Package per Child- $200
- Mental Health Package: $300
  - Includes services for psychiatry and therapy. This is best for families who see our psychiatrist and one of our therapists.

A la carte option available

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	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	$40.00 per medication per refill