THIRD PARTY BILLING
You are responsible for paying ambulance services provided to you by SouthBridge EMS, except as covered in this Membership Contract. SouthBridge EMS will file claims with all third party insurers, including Medicare. As a subscriber, you must agree to take all steps necessary to obtain maximum reimbursement from your insurance carrier. If you receive payments from your insurance carrier, you MUST FORWARD THE PAYMENTS TO SOUTHBRIDGE EMS at the address on the front of this form. If you do not forward payment to SouthBridge EMS, you will be billed for this amount.
WHY SHOULD I SUBSCRIBE TO SOUTHBRIDGE EMS IF I HAVE MEDICARE
OR OTHER INSURANCE?
Medicare and most insurance plans will not cover 100 of the bills incurred for ambulance service. An ambulance subscription can help reduce these out-of-pocket expenses. If 100% of your deductible has been met and your insurance company correctly processes and reimburses any portion of that bill, we accept it as payment in full provided the policyholder has complied with their insurance carrier's payment procedures. If 100% of your deductible HAS NOT been met, you will be charged 50% of your ambulance bill. No copayments under $200.00 will be billed to you. Non-subscribers will be billed the full balance and all copayments.
For more information regarding coverage please call 412-221-5115 ext.200
Services not covered by the ambulance subscriptions are routine (non-emergency) transports, including but not limited to:
Non-medically necessary hospital discharges
Transports to and from physicians' offices
Non-medically necessary ambulance transports
Failure of a subscriber to take all necessary steps required by their insurance carrier to obtain maximum reimbursement
Subscribers, who have met their deductibles, will not be billed for any MEDICALLY NECESSARY EMERGENCY ambulance service WITHIN THE SERVICE AREA OF SOUTHBRIDGE EMS, provided the conditions of an EMERGENCY have been met. Subscribers who have not met 100% of their deductible will be charged 50% of their ambulance bill. Copayments under $200.00 will not be billed to you. UNINSURED SUBSCRIBERS WILL BE BILLED 50% OF THEIR AMBULANCE BILL.
WHAT IS AN EMERGENCY?
The Health Care Financing Administration ties the definition of emergency ambulance service to the statutory definition of emergency services in a hospital room. The term "emergency" means services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of such severity that the absence of immediate attention could reasonably be expected to result in the following:
Placing the patient's health in serious jeopardy
Serious impairment to bodily functions
Serious dysfunction of any bodily organ or part
This subscription will terminate on the date indicated on the front of this form. YOUR SUBSCRIPTION WILL IMMEDIATELY TERMINATE WHEN YOU RELOCATE OUTSIDE OF OUR PRIMARY SERVICE AREA. SouthBridge EMS will not be responsible for the reimbursement of any other ambulance service.
PROOF OF MEMBERSHIP
Your check or credit card statement is your receipt. If you are transported, your membership will be verified by our staff.
Subscription payments are nonrefundable.