Good Faith Estimate rights and financial policy

Patient responsibility

Patients are responsible for charges they are legally obligated to pay, subject to applicable law and payer contracts. Listing another person in this intake does not by itself make that person a guarantor; any separate guarantor agreement must identify the person accepting financial responsibility. Cosmetic consultations and procedures are commonly excluded from insurance coverage. If Meridian checks benefits or submits a claim, you remain responsible for noncovered services, deductibles, coinsurance, copayments, and balances allowed by law and the applicable payer contract.

Estimates and separate bills

An estimate is not a bill or guarantee. Your care may change based on medical needs. Hospitals, surgery centers, anesthesia professionals, laboratories, pathology services, imaging centers, pharmacies, or other clinicians may bill separately. Ask each provider or facility for its own estimate; an estimate from Meridian may not include their charges.

Federal Good Faith Estimate rights

If you have no insurance coverage for the services or choose not to use eligible health coverage, you have the right to a written Good Faith Estimate of expected charges at no charge. For nonemergency care scheduled at least three business days in advance, an estimate must generally be provided without requiring a separate request. You may also request one before scheduling. It will be provided on paper or electronically according to your preference.

• Care scheduled 3–9 business days in advance: the estimate is generally due within one business day after scheduling.
• Care scheduled at least 10 business days in advance: the estimate is generally due within three business days after scheduling.
• An estimate requested before scheduling: the estimate is generally due within three business days after the request.

If a bill is higher than the federal estimate

If the total billed charges from a provider or facility are at least $400 more than that provider’s or facility’s expected charges on your Good Faith Estimate, you may be eligible for the federal patient-provider dispute process. Start a dispute within 120 calendar days of the date you receive the initial bill containing the disputed charges. Keep the estimate and bill. Visit cms.gov/nosurprises or call 1-800-985-3059 for eligibility, filing instructions, and the applicable administrative fee. You may also ask Meridian to review the bill; doing so does not extend the federal filing deadline. Using the federal dispute process will not adversely affect your care.

Indiana estimate rights

Indiana also provides rights to request an estimate for certain ordered, scheduled, or referred nonemergency services, subject to the law’s coverage and exceptions. Where Indiana’s practitioner estimate requirement applies, a requested estimate is provided at no charge and is generally due within two business days after the necessary information is received, is nonbinding, and is valid for 30 days. These state terms do not replace federal Good Faith Estimate or dispute rights. Call Meridian for an estimate or to ask which protections apply to your care.

Practice-specific payment terms

Meridian’s practice-specific payment terms—including payment timing, deposits, cancellation or rescheduling charges, refunds, payment plans, card-on-file practices, and collection terms—will be provided separately when applicable. Any procedure-specific estimate or financial agreement will be presented separately before payment or scheduling.

Questions

Ask for an itemized statement or call Meridian at 317-575-0330 with billing or estimate questions. Signing this policy does not waive any federal or Indiana estimate or dispute right.