ADHS Licensed Facility Appointments: (602) 456-2860

Legal & patient rights

Financial Policy

Effective Date: September 1, 2026

1. Overview

LoDo Pain, LLC provides specialty chronic pain evaluation and medication-management services.

LoDo Pain accepts Original Medicare for eligible covered services and is enrolled as a provider with the Arizona Health Care Cost Containment System (“AHCCCS”). Participation with individual Medicare Advantage, AHCCCS, and commercial health plans may vary.

LoDo Pain also offers self-pay services when permitted by law and applicable insurance-program requirements.

This Financial Policy explains insurance billing, patient payment responsibilities, self-pay arrangements, and related administrative policies. By scheduling or receiving services, you acknowledge and agree to the provisions applicable to your coverage and services.

2. Insurance Information and Eligibility Verification

Patients must provide complete and accurate insurance information before receiving services and must notify LoDo Pain promptly of any changes.

Verification of eligibility or benefits is not a guarantee of:

  • Coverage
  • Authorization
  • Medical necessity
  • Claim payment
  • Network participation
  • Acceptance into the practice
  • Any particular treatment or prescribing decision

Coverage is determined by the patient’s insurance plan based on the patient’s eligibility, benefits, authorization requirements, network status, medical necessity, and other plan rules in effect on the date of service.

Patients are responsible for understanding their benefits and for amounts lawfully assigned to them by their insurance plan.

3. Original Medicare

LoDo Pain accepts Original Medicare for eligible, medically necessary covered services furnished by Medicare-enrolled providers.

When Medicare billing applies:

  • LoDo Pain will submit claims for covered services to Medicare.
  • Patients are responsible for applicable deductibles, coinsurance, and non-covered services, subject to federal law.
  • Supplemental insurance may be billed when sufficient and accurate information is provided.
  • Medicare coverage and payment are not guaranteed merely because a service is recommended or performed.
  • Medicare will not pay for services that do not satisfy its coverage, documentation, frequency, medical-necessity, or other requirements.

When required, patients will receive advance notice before a service that LoDo Pain reasonably believes Medicare may not cover. The notice will explain the service, the reason coverage may be denied, and the estimated patient responsibility.

LoDo Pain will not charge Medicare beneficiaries separate intake, administrative, membership, monitoring, or access fees when those charges duplicate, bundle with, or are otherwise attributable to Medicare-covered services.

4. Medicare Advantage Plans

Medicare Advantage plans are administered by private insurance companies and maintain their own provider networks, authorization requirements, and coverage rules.

LoDo Pain’s enrollment in Original Medicare does not automatically make LoDo Pain in-network with a patient’s Medicare Advantage plan.

Before services are provided, LoDo Pain may need to confirm:

  • Whether LoDo Pain and the treating provider are in-network
  • Whether the patient has out-of-network benefits
  • Whether a referral or prior authorization is required
  • Whether the plan will approve services on an individual or single-case basis

If LoDo Pain is not contracted with the patient’s Medicare Advantage plan and the plan does not authorize out-of-network services, the patient may need to obtain care from an in-network provider. Patients will not be treated as self-pay for Medicare-covered services when doing so would violate Medicare or plan requirements.

Prior authorization is not a guarantee of claim payment.

5. AHCCCS and AHCCCS Health Plans

LoDo Pain is registered or enrolled with AHCCCS. However, AHCCCS enrollment does not necessarily mean LoDo Pain is contracted with every AHCCCS health plan.

LoDo Pain is completing or may continue to complete credentialing and contracting with individual AHCCCS health plans. Until participation is confirmed, a plan may:

  • Consider LoDo Pain out-of-network
  • Require prior authorization
  • Approve treatment on an individual or case-by-case basis
  • Require the patient to receive services from another provider
  • Decline to cover services at LoDo Pain

LoDo Pain will verify the patient’s AHCCCS eligibility, assigned health plan, network status, and authorization requirements before providing nonemergency services whenever reasonably possible.

AHCCCS members will not be charged for covered services except for copayments, cost-sharing, or other amounts expressly permitted by AHCCCS and the patient’s health plan. LoDo Pain will not deny services based on inability to pay a nonmandatory AHCCCS copayment when prohibited by AHCCCS rules.

An AHCCCS member may be financially responsible for a noncovered service only when charging the member is permitted by law and program requirements and the member receives any required advance notice and knowingly agrees in writing to accept financial responsibility.

6. Patients With Both Medicare and AHCCCS

Patients enrolled in both Medicare and AHCCCS must disclose both forms of coverage.

Medicare will generally be billed as the primary payer when applicable, and AHCCCS or the patient’s AHCCCS health plan may be billed as the secondary payer in accordance with applicable coordination-of-benefits requirements.

Qualified Medicare Beneficiaries and other protected beneficiaries will not be billed for Medicare deductibles, coinsurance, or copayments when federal or state law prohibits such billing.

7. Commercial Insurance and Self-Pay Services

Unless LoDo Pain has confirmed participation with a particular plan, LoDo Pain does not routinely bill commercial insurance for clinical services.

Self-pay arrangements may be available for:

  • Patients without applicable insurance coverage
  • Services that are not covered by a patient’s insurance
  • Services provided outside an insurance benefit when permitted by law
  • Patients whose commercial insurance LoDo Pain does not accept
  • Payment is due at or before the time of service unless otherwise agreed in writing.

Self-pay availability is subject to Medicare, Medicaid, AHCCCS, contractual, and other legal requirements. Medicare and AHCCCS beneficiaries may not elect to pay privately for covered services when private payment would violate applicable program rules.

Patients may use insurance separately for prescriptions, laboratory services, imaging, or other services furnished by independent third parties.

Payment does not guarantee acceptance into the practice, any particular treatment, prescription, medication, dose, or continuation of care.

8. Patient Payment Responsibilities

A valid payment method may be required for lawful patient-responsibility amounts.

Patients may be responsible for:

  • Deductibles
  • Coinsurance
  • Permitted copayments
  • Noncovered services accepted by the patient after any required advance notice
  • Self-pay services
  • Missed-appointment or late-cancellation charges when permitted
  • Other amounts properly assigned to the patient under applicable law and plan requirements

Insurance-related amounts may be collected at the time of service based on the information reasonably available. After the claim is processed, the patient’s responsibility may be adjusted to correspond with the explanation of benefits or remittance advice.

Outstanding balances must be resolved before future scheduling, except when restricting services would violate Medicare, AHCCCS, contractual, legal, ethical, or patient-safety requirements.

9. Intake Screening and Initial Evaluation

Prospective patients must complete an intake screening before an initial evaluation is scheduled.

The screening process may include:

  • Collection and review of prior medical records
  • Preliminary review of the patient’s condition and treatment history
  • Insurance eligibility and network review
  • Identification of referral or authorization requirements
  • Determination of whether LoDo Pain may be an appropriate clinical setting

For eligible Medicare or AHCCCS patients, LoDo Pain will not impose a separate intake, record-review, administrative-setup, or consultation fee when that work is covered, bundled into a covered service, or may not lawfully be billed separately to the patient.

A separate fee may apply to a genuinely noncovered administrative or self-pay service when permitted by law. Any applicable fee will be disclosed before the service is performed.

Completion of screening, insurance verification, authorization, or payment does not guarantee acceptance into the practice or any particular treatment or prescription.

10. Care Access Plan

Certain eligible self-pay patients may be offered enrollment in a Care Access Plan for specified noncovered services.

Care Access Plan fees may:

  • Be billed automatically on the first day of each month
  • Be prorated for the initial month
  • Become non-refundable once the billing period begins

Cover specifically identified noncovered access or administrative services

The plan does not guarantee:

  • Prescription of any medication
  • Continuation of any medication or treatment
  • Dose escalation
  • Acceptance into or continued participation in the practice
  • Any particular clinical outcome

A Care Access Plan fee will not be charged to a Medicare or AHCCCS beneficiary when the fee duplicates, includes, or conditions access to covered services. Participation in a private plan will not be required as a condition of receiving covered Medicare or AHCCCS services.

Written notice must be provided before the next billing cycle to discontinue enrollment.

11. Enhanced Monitoring

Certain treatment plans may require enhanced clinical monitoring based on clinical risk factors, medication regimens, applicable standards, and clinic safety protocols.

Monitoring may include:

  • Urine or other drug testing
  • Additional clinical assessment
  • Medical-record review
  • Pharmacy coordination
  • Prescription-monitoring-program review
  • Additional oversight associated with controlled medication management

Required monitoring does not imply wrongdoing or noncompliance.

When monitoring is part of a covered service, LoDo Pain will bill the applicable payer and collect only the amount properly assigned to the patient. A separate Enhanced Monitoring Fee will not be imposed when it duplicates a Medicare- or AHCCCS-covered service.

A disclosed self-pay fee may apply to noncovered monitoring only when permitted by law and accepted by the patient in advance.

12. AutoPay and Recurring Payments

Patients who voluntarily enroll in AutoPay authorize LoDo Pain to charge the payment method on file for disclosed self-pay fees and lawful patient-responsibility amounts.

If an AutoPay transaction fails, is declined, reversed, or disputed, any applicable self-pay AutoPay discount may be removed for that billing period and the standard disclosed self-pay rate may apply.

AutoPay discounts do not apply to Medicare- or AHCCCS-covered services when applying a discount or additional charge would conflict with program requirements.

Patients may revoke recurring-payment authorization prospectively by providing written notice, but remain responsible for valid charges incurred before revocation.

13. Prior Authorizations, Referrals, and Claim Denials

Patients are responsible for cooperating with requests for insurance information, referrals, records, and authorization documentation.

LoDo Pain may assist with authorization requests, but approval is determined by the payer. Authorization does not guarantee payment.

If a claim is denied, LoDo Pain will determine whether the denial should be corrected, appealed, written off, billed to another payer, or assigned to the patient. Patients will be billed only when permitted by law, the applicable payer contract, and program requirements.

14. Nonpayment and Administrative Action

Failure to pay a valid patient-responsibility amount may result in:

  • Collection notices
  • Appointment cancellation or rescheduling
  • Suspension of nonurgent scheduling
  • Discontinuation of optional self-pay services
  • Administrative discharge, subject to clinical review and applicable notice requirements

LoDo Pain will not deny covered services solely because an AHCCCS member cannot pay a nonmandatory copayment when such denial is prohibited.

Any limitation or discharge will be handled in accordance with applicable law, payer requirements, professional obligations, and patient-safety considerations.

15. Refunds and Account Credits

Fees for completed self-pay appointments, completed noncovered services, and Care Access Plan billing periods are generally non-refundable once the service has been rendered or the billing period has begun.

Insurance overpayments and patient credits will be handled in accordance with Medicare, AHCCCS, payer-contract, and applicable refund requirements.

Refunds may be issued for:

  • Duplicate payments
  • Verified billing errors
  • Overpayments
  • Services canceled within the applicable cancellation period
  • Other circumstances requiring a refund by law or payer rules

Approved refunds are generally returned to the original payment method within 7–10 business days.

A processing adjustment of up to 3% may be deducted from a voluntary self-pay refund only when permitted by law. No processing adjustment will be deducted from a refund required by Medicare, AHCCCS, an insurance contract, or applicable law.

16. Missed Appointments and Cancellations

Appointments must be canceled at least one business day in advance.

Missed appointments or late cancellations may result in:

  • A missed-appointment fee
  • Forfeiture of an eligible prepaid self-pay visit fee
  • Rescheduling restrictions
  • Administrative review after repeated occurrences

Missed-appointment fees are not billed to Medicare, AHCCCS, or another insurer. Such fees will be charged to a patient only when permitted by applicable law and payer requirements and disclosed in advance.

17. Third-Party Services

Pharmacy services, laboratory testing, imaging, and other ancillary services may be furnished and billed by independent third parties.

Patients are responsible for confirming whether a third-party provider is covered by their insurance plan. LoDo Pain cannot guarantee another provider’s network status, authorization, billing practices, or coverage decisions.

18. Good-Faith Estimates

Uninsured and eligible self-pay patients may have the right to receive a good-faith estimate of expected charges under federal law.

A good-faith estimate is based on information reasonably available when it is prepared. Actual charges may differ if the patient’s needs, treatment plan, or required services change.

19. Billing Questions and Disputes

Patients should review all statements and explanations of benefits promptly.

Questions or suspected billing errors should be submitted to:

Email: info@lodopain.com

Whenever possible, patients should contact LoDo Pain within 30 days of the statement or charge. This requested timeframe does not reduce any appeal, dispute, refund, or other right available under Medicare, AHCCCS, an insurance plan, or applicable law.

20. Important Notice

Payment, insurance coverage, authorization, or enrollment in any optional self-pay program does not guarantee:

  • Acceptance into the practice
  • Evaluation for controlled substances
  • Prescription of any medication
  • Dose escalation
  • Continuation of a particular medication or treatment
  • A particular clinical outcome
  • Continued eligibility for a structured care program

All clinical decisions are made by licensed healthcare providers based on medical judgment, patient safety, applicable standards of care, and federal and Arizona law.

If any provision of this Financial Policy conflicts with Medicare, AHCCCS, a controlling payer contract, or applicable law, the governing program requirement, contract, or law will control.