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BIOVISION DIAGNOSTICS OUT-OF-NETWORK BILLING AND PAYMENT AGREEMENT


THIS POLICY DOES NOT APPLY TO REQUESTS FOR DIETITIAN SERVICES OR LABORATORY TESTING FOR: BlueCross Blue Shield PPO, BlueCross BlueShield Federal, HealthLink, Tricare, and Medicare insurance plans.

By ordering clinical laboratory or registered dietitian services from Biovision Diagnostics LLC and proceeding with payment, you acknowledge and agree to the following terms regarding our out-of-network billing and payment policies:

  • Out-of-Network Provider Status: Biovision Diagnostics LLC is not an in-network provider with your insurance plan. We do not have a contract with your insurance company, and you are responsible for paying the full cost of services at the time of ordering.
  • Upfront Payment: You agree to pay the full cost of services upfront via credit card when placing your order. Within 15 business days of payment, we will provide an itemized receipt and a complete HCFA 1500 (CMS-1500) claim form, which you may submit to your insurance company for potential reimbursement.
  • No Guarantee of Reimbursement: Biovision Diagnostics LLC does not guarantee that your insurance company will reimburse you for any portion of the services provided. Reimbursement depends on your insurance plan’s out-of-network benefits, deductible, coverage limitations, and other factors determined solely by your insurer. We strongly recommend contacting your insurance company before ordering to verify your out-of-network coverage and understand your financial responsibility.
  • Responsibility for Out-of-Network Benefits: You acknowledge that it is your responsibility to understand your insurance plan’s out-of-network benefits, including reimbursement rates, deductibles, co-insurance, and any exclusions or limitations. Biovision Diagnostics LLC is not responsible for discrepancies between expected and actual reimbursement from your insurance company.
  • Claim Submission: We will provide a completed HCFA 1500 form with accurate details of the services provided, including CPT codes, ICD-10 diagnosis codes, and billed charges. You are responsible for submitting the claim form to your insurance company in a timely manner and following up on the claim’s status. Biovision Diagnostics LLC is not liable for claims denials or delays due to submission errors, insurance policies, or other factors beyond our control.
  • Non-Refundable Payments: Payments made to Biovision Diagnostics LLC are non-refundable, regardless of whether your insurance company approves or denies your reimbursement claim. Any reimbursement you receive from your insurance company is yours to retain, as you have paid Biovision Diagnostics LLC in full.
  • Additional Costs: You may be responsible for additional costs if further services, tests, or consultations are required. These will also require upfront payment and follow the same out-of-network billing process.
  • Electronic Agreement: By proceeding with payment, you confirm that you understand and accept these terms, including your responsibility for full upfront payment, the lack of guaranteed reimbursement, and the need to verify your out-of-network benefits with your insurance company.

For questions about our billing policies or assistance with the HCFA 1500 claim process, please call us at 618-690-9555 during regular business hours. We are happy to provide guidance but cannot act as a liaison between you and your insurance company.

I AGREE: By submitting your order, you agree to the terms of this Out-of-Network Billing and Payment Agreement.