Financial Policy

Key Terms Used in This Policy

Guarantor

The adult who is financially responsible for the account and who receives statements.

Patient responsibility

The amounts your health plan assigns to you — copays, coinsurance, deductibles, and charges for services your plan does not cover.

Time of service

Check-in for the visit.

Self-pay

A visit for which no verifiable insurance is billed, including visits where we cannot verify coverage.

Fees at a Glance

1. Registration, Identification & Insurance Information

1.1 Identification and insurance cards. At every visit, the adult bringing the patient must present a valid government-issued photo ID and the patient’s current insurance card(s). We scan or copy these for our records so that we can bill your insurance accurately and on time. Without a current card, we cannot verify coverage and the visit will be treated as self-pay (Section 4).

1.2 Changes to your information. Notify us immediately of any change in insurance, address, telephone number, email, employment, or legal guardianship. If a claim is denied because we were not given accurate, current information — including denials for untimely filing — the full balance becomes your responsibility.

1.3 More than one insurance (coordination of benefits). When a child has more than one plan, insurance rules require us to bill in a specific order. Under the “birthday rule,” the plan of the parent whose birthday falls earlier in the calendar year is primary, unless a court order or your plans’ rules provide otherwise. AHCCCS/Medicaid is always the payer of last resort, and military plans (TRICARE) generally pay after other health insurance. You must report every plan that covers your child. If you do not, the total balance is your responsibility, and we may be required to refund a payer and rebill.

1.4 Timely filing. Insurance companies require claims to be filed within their timely-filing limits. We do our best to meet every requirement of our insurance contracts. Your failure to provide accurate, current insurance information — or to notify us of changes — moves responsibility for payment to you.

1.5 Network participation and primary care assignment. Please confirm that MGPP is in network with your plan before your visit. For HMO and AHCCCS plans, also confirm that MGPP (or your child’s MGPP provider) is listed as the primary care provider (PCP) on each child’s card. If we are not in network or not the assigned PCP, your plan may deny the claim or pay a reduced amount; the visit may then be rescheduled or treated as self-pay.

1.6 Referrals and prior authorizations. Some plans require a referral or prior authorization for specialist visits, testing, imaging, medications, or behavioral health services. We will help obtain authorizations for services we order, but it is your responsibility to know your plan’s requirements and confirm they are in place. Charges denied because a required referral or authorization was not obtained become your responsibility.

1.7 Newborns. Contact your insurance company as soon as possible after your baby is born. Most plans allow only a limited window — often 30 days — to add a newborn; if you miss it, you may have to wait until open enrollment. Until your newborn is added and we can verify eligibility, newborn visits are billed as self-pay and payment is due at the time of service. Once coverage is confirmed retroactive to birth, we will bill your plan and refund or adjust any overpayment.

2. Understanding Your Benefits: Services Your Plan May Not Cover

2.1 Routine and preventive services. Well visits; camp, school, and sports physicals; immunizations; and other routine services may not be covered by some plans. It is your responsibility to verify coverage for your child before the visit.

2.2 Hearing and vision. Hearing and vision screenings are often not covered.

2.3 Additional services during a well visit. During a periodic or annual health exam, additional tests or procedures — hearing and vision screening, immunizations, laboratory tests — may be ordered. If you raise concerns that require evaluation beyond the scope of a routine exam, AMA/CPT coding guidelines require us to bill an additional office visit for that additional service. Insurance carriers do not treat those additional services as part of the preventive exam, so they are subject to any copay, deductible, coinsurance, or plan restriction that applies — even when the well visit itself is paid at 100%. Your provider can discuss these criteria with you.

2.4 Sick on the day of a well visit. We can see your child for the sick visit and reschedule the well visit, or see your child for both on the same day. Insurance may not pay for both a well visit and a sick visit on the same day, and you may be responsible for any remaining balance.

2.5 Nurse visits. A throat culture and/or strep test alone is considered a nurse visit; an office visit charge applies in addition to the charge for the lab test(s).

2.6 Mental and behavioral health. Mental health benefits are often different from medical benefits. Common conditions — ADD/ADHD, developmental delays, learning disorders, depression, anxiety, autism, psychological testing, and others — are usually processed under the mental health portion of a plan, which may carry different copays, deductibles, networks, or authorization requirements.

2.7 Telephone services. Telephone Evaluation and Management services by your physician, and Telephone Assessment and Management services by our nurses, are billed to your insurance plan and are subject to your plan’s cost sharing. At this time we do not provide or bill email/internet-based Evaluation, Assessment, or Management services.

2.8 Outside laboratories and other providers. Laboratories (including Sonora Quest), imaging centers, hospitals, emergency rooms, specialists, and other providers bill you separately under their own financial policies. Please direct questions about those charges to them.

2.9 Your Explanation of Benefits (EOB). After we bill your plan, you should receive an Explanation of Benefits from your insurance company. Review it for consistency with your plan’s allowances and with the services rendered. For questions about how your benefits were determined, call your plan’s member services department or your employer’s Human Resources department. For questions about the services we billed, call Patient Account Services at 480-745-3702.

3. Payment at the Time of Service

3.1 Copayments. Our contracts with insurance plans require us to collect all copayments at the time of service; we are not permitted to waive them. You are responsible for knowing the copayment amount for each child’s plan.

3.2 HMO plans. Copayment is due at check-in. The amount varies by plan.

3.3 PPO and high-deductible plans. Until your plan’s deductible for the year has been met, payment for the visit is due at the time of service, based on your plan’s allowed amount if known or on our estimated charge. After the deductible is met, your copayment or estimated coinsurance is due at the time of service. Once your plan processes the claim, any difference between the amount collected and your actual patient responsibility will be billed to you or refunded.

3.4 Balances determined after billing. If we must bill your insurance to determine your coinsurance or deductible balance, payment is due within 30 days of the statement date.

3.5 Unpaid copay fee. A copayment that is not paid on the day of the visit is subject to an additional $10.00 administrative fee.

3.6 Rescheduling for unpaid amounts. Appointments may be rescheduled if there is an outstanding balance or if a copayment is not paid at the time of service. We will not delay urgently needed medical care because of a balance — please speak with our staff.

3.7 Administrative fees. Missed-appointment, form, letter, records, and other administrative fees in this Policy are not covered by insurance, cannot be billed to your plan, and are due before or at your next appointment.

4. Self-Pay Patients

4.1 Full payment is required at the time of service.

4.2 If you do not have the patient’s insurance card at check-in and we cannot verify coverage, the visit is treated as self-pay. If you later provide proof of coverage that was active on the date of service, we will bill your plan within its timely-filing limit and refund or adjust any overpayment.

4.3 For self-pay patients, laboratory and imaging services are sent to or performed through Sonora Quest Laboratories, which bills you separately.

4.4 Vaccines for Children (VFC). For uninsured and other VFC-eligible children, the VFC Program provides the vaccine itself at no cost. A vaccine administration fee of $21.00 per vaccine applies. Consistent with VFC Program requirements, we will not deny a VFC vaccine to an established patient because the parent or guardian is unable to pay the administration fee.

4.5 Good Faith Estimate. If your child is uninsured, or you choose not to use insurance, federal law gives you the right to a Good Faith Estimate of expected charges for scheduled services. Ask for one when you schedule, or at any time.

5. Guarantor & Family Accounts

5.1 Who is responsible. The adult who accompanies a minor to a visit and/or the legal parents or guardians are responsible for full payment — regardless of insurance coverage, custody arrangement, divorce decree, or any court order allocating medical expenses between parents. That adult is set up as the guarantor (the person who receives statements) and must provide complete demographic and identification information, including both parents’ dates of birth and Social Security numbers, current address, and telephone numbers. We use this information for identity verification, claims processing, and account collection, and we safeguard it under our Notice of Privacy Practices.

5.2 Disputes between parents. MGPP will not become involved in negotiating between parents or guardians in legal disputes and will not divide a single visit between two accounts. To change the guarantor, the person who will receive future statements must complete and sign a Change of Guarantor Form.

5.3 Other adults bringing your child. If someone other than a parent or legal guardian — a grandparent, relative, or caregiver — brings your child, that adult must have written authorization from a parent or guardian to consent to treatment and should be prepared to pay amounts due at the time of service. The parent or guardian remains the guarantor.

5.4 Patients age 18 and older. Patients age 18 and older are responsible for their own accounts unless another adult has agreed in writing to act as guarantor.

6. Statements, Payment Plans & Refunds

6.1 Statements. We provide an itemized statement each time your child receives services, and periodic statements while a balance remains. Balances are due within 30 days of the statement date unless prior arrangements have been made with Patient Account Services.

6.2 Questions and disputes. If you believe a statement is incorrect, contact Patient Account Services within 30 days of the statement date so we can review it. Any undisputed portion of the balance remains due.

6.3 Payment plans. If you cannot pay a balance in full, contact Patient Account Services before the balance becomes past due. Payment plans are documented in a written agreement, require a minimum monthly payment and a payment method kept on file for automatic payments, and remain in good standing only while payments are made on schedule. If two payments are missed, the plan is void and the full remaining balance is due immediately under Section 7.

6.4 Returned checks. A $25.00 fee is added to your account for any check returned for non-sufficient funds, and the account is placed on a “cash-only basis” — we will accept payment only by cash or credit card until the balance is cleared.

6.5 Credit balances and refunds. Credits are first applied to any other outstanding balance on the same guarantor account. Remaining credits are refunded within 30 days after the credit is confirmed (once your plan has finished processing the claim). Overpayments made by an insurance plan are returned to the plan.

7. Unpaid Balances & Collections

7.1 Balances are due within 30 days of the statement date unless prior arrangements have been made with Patient Account Services. If a balance is not paid by the due date, we send a second request for payment.

7.2 A $25.00 rebilling fee is added to any balance that remains outstanding more than 90 days, and a certified final (third) request for payment letter is issued.

7.3 Balances not paid in full within 10 days of the date on the final request letter are forwarded to a collection agency. The guarantor is then responsible for the amount due plus all costs of collection permitted by law and by this agreement, including but not limited to: all collection expenses charged by the collection agency; court costs; reasonable attorney’s fees; and the reversal of any discounts previously applied to the account.

7.4 If your account is forwarded to a collection agency, appointments will be cancelled and/or rescheduled until the account is paid in full or a written payment arrangement is approved. Accounts referred to collections may also result in discharge from the practice under our Office Policy.

7.5 MGPP and any agency acting on its behalf comply with applicable federal and Arizona laws governing the collection of medical debt.

8. Missed Appointments, Late Cancellations & Late Arrivals

8.1 Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time reserved for your child. We reserve the right to charge a fee for cancelled or missed appointments.

8.2 Notice. Cancellations require at least 24 hours’ notice before the appointment. An appointment cancelled with less than 24 hours’ notice, or simply not kept, is a missed appointment.

8.3 Fee. A $50.00 fee is charged for each missed appointment (each child’s appointment is a separate appointment). This fee is not covered by insurance and is due before the next scheduled appointment.

8.4 Late arrivals. If you arrive more than 15 minutes after the scheduled appointment time, we may need to reschedule your visit; a visit rescheduled for late arrival is treated as a missed appointment.

8.5 Repeated missed appointments. After a third missed appointment within a family in any 2-year period, the family will receive written notice and will continue to be seen for 30 days for urgent needs while establishing care with another practice. After that period, we must discharge the family from the practice due to a failed professional relationship. Records are transferred to the new provider at no charge (Section 9.3). Please review our Office Policy for details.

9. Forms, Letters & Medical Records

9.1 School and childcare forms. A school/childcare form is provided at no cost at every well-child examination. Please keep the original and photocopy it for your child’s school, camp, or activity — this helps you avoid additional fees. Forms requested outside the well-child examination require a $10.00 prepayment per form for review and completion; please allow up to 5 business days.

9.2 Letters and alternative vaccine schedules. A $25.00 fee applies to physician letters and to visits for alternative vaccine schedules. These fees are not billable to insurance.

9.3 Medical and payment records. Requests for copies of medical or payment records must be made in writing and are fulfilled within the time required by law (generally within 30 days). Paper copies requested for personal use are subject to a $35.00 fee, or the lesser amount permitted by HIPAA and Arizona law, payable in advance. We do not charge for the pertinent information in medical records provided: (a) to another health care provider who is providing continuing care to the patient; (b) to the patient for the demonstrated purpose of obtaining health care; or (c) to the patient’s health care decision maker for the demonstrated purpose of obtaining health care for the patient.

10. Injuries Caused by Others (Third-Party Liability)

If your child is treated for an injury that may be another party’s responsibility — a motor vehicle accident, an injury on someone else’s property, or a similar claim — we bill your health plan as usual, and the guarantor remains responsible for all patient-responsibility amounts regardless of any pending claim, lawsuit, or settlement. We do not bill automobile insurers, liability carriers, or attorneys unless MGPP has agreed in writing, in advance, to accept a medical lien or letter of protection. Please tell us at check-in when a visit is related to an accident; your health plan may require accident information to process the claim.

11. Membership Programs That Pay Patient Responsibility

If your child is an active member of a patient-responsibility membership program in which our practice participates — for example, Instinctive HealthPass — tell us at check-in and present your membership information. Instinctive HealthPass is a membership program, not health insurance, and it does not replace your health plan. We bill your health plan exactly as usual. When the membership applies, the program pays the eligible patient-responsibility amounts — copays, coinsurance, and deductibles — for eligible in-house services at our practice, under the terms of its membership agreement and our participation agreement with the program. Membership applies only when your qualifying health insurance is active and billed for the visit. It does not apply to self-pay visits, to the administrative fees in this Policy (missed appointments, forms, letters, records), or to charges from outside laboratories or other providers. You remain the guarantor for any amount the program does not pay.

12. Fees & Applicable Law

The fees in this Policy are administrative charges. They are not charged where prohibited by law or by our contract with your health plan — this commonly applies to AHCCCS/Medicaid members — and where a fee exceeds an amount permitted by law, the lawful maximum applies instead.

13. If You Are Having Trouble Paying

14. Changes to the Terms of This Policy

We reserve the right to make changes to this Policy and to make such changes effective for all of our patients and staff. The current version is available at our front desk and upon request. When this Policy changes, MGPP will provide you with a revised Policy upon request. Continued use of our services after a change constitutes acceptance of the revised Policy.

Acknowledgment & Agreement

At your first visit, and whenever this Policy is revised, the guarantor signs an acknowledgment confirming that they have read and understand the Mercy Grace Private Practice Financial Policy (revised September 19, 2026), have had the opportunity to ask questions, and agree to its terms. The acknowledgment includes the following agreements and authorizations:

• Guarantor. I agree to be the guarantor for the patient(s) listed and to be financially responsible for all charges not paid by insurance, including the fees described in this Policy, regardless of custody arrangement or court order.
• Assignment of benefits. I authorize my insurance company(ies) to pay benefits directly to Mercy Grace Private Practice for services provided. I understand this assignment does not relieve me of responsibility for any balance.
• Release of information. I authorize MGPP to release medical and billing information about the patient(s) to my insurance company(ies), their agents, and other payers as needed to process claims and obtain payment.
• Communications. I consent to receive calls, voicemails, text messages, and emails — including automated or prerecorded messages — at the numbers and addresses I provide, about appointments, health reminders, and my account. Consent to text and automated messages is not a condition of treatment, and I may opt out at any time.
• Updates. I understand this Policy may be updated, that the current version is available upon request, and that continued use of MGPP’s services constitutes acceptance of the current Policy.

A printable copy of this Policy and the acknowledgment form are available at our front desk and upon request.