Good Faith Estimate Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provider a "Good Faith Estimate" about out-of-network care. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. The estimate is based on information known at the time the estimate was created. Because Pondera Rehabilitation & Fitness PC is a fixed rate provider, you will always know the cost of your session when you book. A fixed rate means that the amount of time & type of appointment dictates the amount you will be paying. With a fixed rate provider, the amount you spend for an appointment is always known ahead of time and is never more than what it was when you booked. It may turn out to be less if you seek reimbursement from your insurance plan using Reimbursify, a 3rd-party benefit for clients paid for by Pondera Rehabilitation & Fitness PC. Note: A Good Faith Estimate is for your awareness only. It does NOT involve you needing to make any type of commitment. Many clients at Pondera Rehabilitation & Fitness PC do file claims seeking reimbursement after deciding to see an out of network provider with their healthcare service provider using the above service, Reimbursify. It is currently stated that the PHSA (Public Health Service Act) & the GFE do not apply to any clients who are using insurance benefits, including "out of network benefits (i.e.., submitting superbills to insurance for reimbursement). However, because some of our clients have other variable insurance plans with as-yet-unseen stipulations, at this time we are requiring all non- fitness based clients to complete this form until the greater details of the 2022 law are more clear for fixed rate providers. The Good Faith Estimate states that it does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur and will be provided a new "Good Faith Estimate" should this occur. It is not clear under what circumstance this would ever occur within Pondera Rehabilitation & Fitness PC. If this happens, federal law allows you to dispute (appeal) the bill if you and your therapist have not previously talked about the change and you have not been given an updated good faith estimate. The times that this occurs are usually for services rendered in emergency rooms, or planned facilities where the facility may be in-network but a certain provider is not necessarily in your network and that leads to surprise billing. For example, a planned surgery for a total knee replacement, where an on-call back up anesthesiologist is needed but they are not in-network and you are charged for that individual’s services as an out of network provider. This is obviously not the care that Pondera Rehabilitation & Fitness PC is involved in. Under Section 2799B-6 of the (PHSA), health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request, or at the time of scheduling health care items and services to receive a "Good Faith Estimate" of expected charges. Common Service Codes (CPT) at Pondera Rehabilitation & Fitness PC: For fixed rate providers, we do not have set dollar amounts for each code. The total appointment session has a fixed rate so the amount for each code Page 1 of 6is determined by that total time (i.e.; 60 minutes, 90 minutes, etc). 97167 | Initial Evaluation (not a timed code) 97168 | ReEvaluation (not a timed code) 97110 | Therapeutic Exercise (each 15 minutes or portion there of) 97112 | Neuromuscular/NeuroMotor Rehabilitation (each 15 minutes or portion there of) 97140 | Manual Therapy (each 15 minutes or portion there of) 97530 | Therapeutic Activity (each 15 minutes or portion there of) 97535 | Self Care/Activities of Daily Living (each 15 minutes or portion there of) 97150 | Group Therapy (each 15 minutes or portion there of) Common Diagnosis Codes at Below are common diagnosis codes at Pondera Rehabilitation & Fitness PC ; however, the list is not at all exhaustive. With that said, diagnosis codes can change based on many factors. Understand that often a number of diagnoses may be listed to be sure that you are covered for any issues where an insurance company may not pay for certain codes in certain states on on certain plans. Please speak to your therapist with any questions or concerns. Other lack of coordination/poor motor planning/motor dyspraxia (R27.8) Other Muscle Spasm (M62.838) Code for Neuralgia and neuritis, unspecified (N79.2) Pain in Right Shoulder (M25.511) Mixed Urinary Incontinence (N39.46) Fecal Incontinence (F15) Constipation (K59.00) Cystocele; prolapse of anterior vaginal wall (N81.10) Pondera Rehabilitation & Fitness PC recognizes every client's therapy journey is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including Ongoing life challenges Your schedule and life circumstances The nature of your specific challenges and how you address them Therapist availability You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change at a re-Evaluation. Where services will be delivered. Pondera Rehabilitation & Fitness PC is both a mobile outpatient practice as well as telehealth. We do not quote insurance benefits, but do provide a worksheet under the FAQs tab of the website (www.ponderarehab.com/faq) for you to contact your insurance about potential reimbursement for out of network coverage. We bill using common CPT codes which are the same for outpatient rehabilitation whether it takes place in a clinical setting, in a home or via telehealth. This is the clinic/office location as well as the mailing and physical address for services: Pondera Rehabilitation & Fitness PC 7311 Galilee Rd Ste 175 Roseville, CA 95678 Business Tax ID Number: 844767181

We are considered an ‘out of network provider’ for all commercial insurances. We do provide Superbills and all medical documentation needed. Additionally, Pondera Rehabilitation & Fitness PC provides a service/free app for our patients called Reimbursify so you do not have to deal with submitting claims, forms or faxing your insurance company. Pondera Rehabilitation & Fitness PC is a registered (traditional) Medicare Provider for InHome (Part B/outpatient) visits only so we do bill them directly. Sliding Fee Scale cases: we update on social media when we are accepting applications for such cases. Please see our other FAQs for more details on related topics such as reimbursement and rates for visits or packages for follow-ups.

You can use a HSA card on file when you register to pay for Rehabilitation and some types of Fitness services. Or, if not paying wiht a HSA, then when you login to your own health insurance plan, you will look for their section on 'out of network' reimbursement or use your HSA process if you did not pay with an attached HSA debit card. All below information is listed on each superbill as well. Reimbursement: We do various types of documentation. Out of that we will then generate what is called a superbill which has the tax ID, the Dx/diagnosis & the CPT/common procedural terms that the insurance companies or HSAs need. Invoices are the payment statement, and are different than superbills. Invoices are found in the communication portal by clicking on the INVOICES tab. Once inside that section, you will be able to see a link on the same line for that ‘date of service’ to then open up each invoice’s superbill if it has been generated for that visit. If you don’t see the superbill in there and you need it, please message us with the date(s) needed so it can be generated for you. NPI/National Provider Identification: Use the Group/Type 2 NPI: 1558953893; When in doubt, use Type 2 NPI. The Individual NPI/Type 1 is NOT typically requested by a reimbursing entity, and you would usually use the preceding Group/Type 2 NPI. Below, the Individual/Type 1 NPI is provided in the rare instance that for some reason it is needed to clarify something. ​​ Individual NPIs: Kirsten Carmichael, DPT, CSCS: 1992015119 Amy Zipp, MS OT/L: 1427134972 Modifier Codes: Occasionally you may be asked for a modifier code; the only ones that we know of that are common for our types of services are the following. If there is other information about this, then we would not know and it would be in the realm of a credentialed medical biller to know more. We do not provide billing services for our rehabilitation except for our contracted medical biller for Medicare patients. GP: services delivered under a Physical Therapy Plan of Care GO: services delivered under an Occupational Therapy Plan of Care​ Reimbursify: We provide a service to assist with reimbursement; however in recent years, more insurers have improved their reimbursement process when you login to your plan provider's portal. Reimbursify has a free app &/or a URL link specific to our organization where you will go to upload your specific health insurance plan information (member ID, subscriber name, etc). Then you’ll be able to use that superbill information to do the rest of the process to get your plan’s reimbursement back to you. They take care of any additional ‘modifier codes’, claim forms and faxing that you would typically need to spend time doing so that you don’t have to do so. The first 5 appointments/date of service (DOS) are paid for by Pondera Rehabilitation & Fitness PC. If there are any additional submissions, they have a fee that at the time of this writing was $2.99/each. The link are below for the free Reimbursify app: https://apps.apple.com/us/app/reimbursify-file-claims-fast/id1243424101 or online portal: https://filefast.reimbursify.com/?qc=PONDE893A Download Reimbursify App Billing services & support: We do not provide medical billing for self-pay services nor communicate with an insurer outside of Medicare which we have a contracted medical biller who is paid to help with this.

Please use this worksheet when contacting your insurance: