BILLING & PATIENT RESOURCES

Potential Patient Payment Notice

PATIENT FINANCIAL INFORMATION
PATIENT PAYMENT INFORMATION

Notice of Potential Patient Payment for Ambulance Services

Insurance, Medicare, and Medicaid coverage requirements can affect the amount a patient may be responsible for paying after ambulance services are provided.

COVERAGE & COST

Why You May Owe an Amount

  • Medicare or Medicaid determines that the trip was not covered, not medically necessary, or did not meet transportation requirements.

  • The transport was beyond the nearest appropriate medical facility, and the additional distance is not covered.

  • Your deductible, coinsurance, copayment, spend-down, or other permitted cost-sharing applies.

  • Your eligibility or coverage was inactive on the date of service, required authorization was not obtained, or the service was outside your plan's network or benefit rules.

  • Another insurer is responsible for payment, or additional information is needed before the claim can be processed.

PATIENT INFORMATION

Your Rights & Next Steps

  • Ask Spirit EMS to explain the expected charge and why coverage may be limited.

  • Keep this notice and review your Medicare Summary Notice, Explanation of Benefits, or Medicaid notice after the claim is processed.

  • If coverage is denied, follow the appeal instructions in the notice from Medicare, Medicaid, or your health plan.

  • Provide current insurance information and any requested medical or authorization records promptly.

Remember: An estimate of potential patient responsibility is not a guarantee of what your insurance plan will pay.