Financial Terms and Conditions

Deductible, Co-Insurance, and Co-Payment
You are responsible for your deductible, co-insurance, and co-payment (if applicable).  Your co-payment is due at the time of service, and co-insurances are settled once the claim is adjudicated.  If your deductible has not yet been met, payment may also be required at the time of service.

Non-Covered Services
If services provided are not covered by your health insurance carrier, you may be responsible for payment for those services.  Your e-signature below constitutes agreement to pay for such services.

Out-of-Network Services
As an out-of-network provider and laboratory, and with the potential of utilizing an out-of-network outpatient surgery facility, none of the parties involved have a contract with your health insurance carrier.  As a result, you may be financially responsible for a higher share of the fees than a provider, laboratory, or facility within your network.  Your signature below constitutes agreement to pay for portion of the out-of-network fees.

Insurance Submission
The insurance process will begin once your procedure has been completed.  There are four entity claims that will be submitted to your insurance on your behalf – surgeon, facility, anesthesia, and pathology.  The insurance may take between sixty and ninety days to finalize all four claims, and possibly longer if an appeal is necessary.  Please refer to the billing page within the FAQ section of our website for detailed information, along with all the appropriate contacts on each entity that submits to your insurance.  Please contact the appropriate parties immediately upon receiving your invoice so that we can begin assisting you with the insurance process.

Member Appeal Representation Authorization
In the event your claim is denied and/or processed below your lower level of benefits, you grant Bespoke Surgical authorization to represent you and act on your behalf regarding your medical health claim determination.