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Payment Policies

Co-payments are due and are collected at Registration before appointment(s). A co-payment amount is determined by the patient’s specific health plan. All co-payments are the responsibility of the patient.

Co-Insurance is a percentage of the cost according to the patient’s health plan for specific medical care and/or treatment. Co-insurance payments are the responsibility of the patient and are due prior to service.

Deposits are required when the service is not covered by insurance or the patient does not have insurance. The Deposit is collected before the appointment and patients will be billed for any additional charges. Deposit amounts may vary by department or type of procedure.

Cancellation Fee: If a patient is a no-show for their appointment or if they cancel their appointment less than 24 hours before their scheduled appointment time, the patient may be responsible for a $30 cancellation fee. Exceptions to the cancellation fee include emergencies and other unavoidable circumstances.

Patients who may have financial difficulties are encouraged to contact a Patient Accounts representative at (805) 681-1760 to discuss a suitable payment plan to meet their financial responsibilities.

Sansum Clinic does not specifically reward providers or other individuals for issuing denials of coverage.

No incentives are paid to physician reviewer to deny services. All denials made regarding medical necessity are reviewed and determined not medically indicated by a physician or specialist reviewer, as appropriate. Review criteria is available to the public upon request to the Managed Care Referrals Department.

Managed Care Referrals Department - Any Utilization Management questions, please contact: 

(800) 281-4425 - California
(800) 472-6786 - Outside of California

     In accordance with California Assembly Bill No. 1278, starting January 1, 2023, physicians and surgeons are required to provide an Open Payments Database notice to patients at the initial office visit. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here.

    The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made
     available to the public. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at: https://openpaymentsdata.cms.gov.

    Conforme a la Ley Núm. 1278 de la Asamblea de California, a partir del 1 de enero de 2023, los médicos y cirujanos están obligados a proporcionar un aviso de Base de Datos de Pagos Abiertos a los pacientes en la visita inicial al consultorio. Solo a efectos informativos, se ofrece aquí un enlace a la página web de Pagos Abiertos de los Centros federales de Servicios de Medicare y Medicaid (CMS).

    La Ley federal de Transparencia de Pagos a Médicos (Physician Payments Sunshine Act) exige que se ponga a disposición del público información detallada sobre pagos y otros pagos de valor superior a diez dólares ($10) por parte de fabricantes de medicamentos, dispositivos médicos y productos biológicos a médicos y hospitales universitarios. La base de datos de Pagos Abiertos es una herramienta federal utilizada para buscar pagos realizados por compañías farmacéuticas y de dispositivos a médicos y hospitales universitarios. Puede encontrarse en la página: https://openpaymentsdata.cms.gov.

    Apollo Managed Care

    Click here or follow this link https://sansum.apollomanagedcare.com/ using validation code 008013.

    Managed Care Referrals Department

    Non-Physician Reviewer Guidelines

    03/2024

    1. Referral request must be
      1. Entered into WAVE or complete and legible on a Request for Treatment form (RFT) is faxed to MCR Dept. 
      2. Submitted by a Clinic physician/office staff 
      3. Reviewed against Clinic approved criteria 
    2. Patient must be eligible and have the benefit. If there is any question regarding eligibility and benefit, contact the HMO and document whom, time and date you spoke to at the HMO with benefit information. 
    3. Review 
      1. Referral must be to a contracted provider unless there is not a clinic provider whom can provide the service. 
      2. Procedures/Providers available in-Clinic must include reason for out-of-Clinic referral. 
      3. Managed Care Referrals Dept. (MCR) may contact Department Manager to assist in Clinic scheduling. 
      4. All denials must be signed by Medical Director or a Physician Reviewer. 
      5. Patients eligibility and benefit must be verified and documented before giving to RN Reviewer 
      6. Verify patient does not have carve-out coverage for psych, vision, hearing, eyeglass hardware, hearing aide, chiro, acupuncture, or diabetic supplies/self injectables as a pharmacy benefit and document on Athena referral this was verified with Health Plan.* 
      7. Check to be sure service is not capitated (i.e. HME & IV therapy for Health Net & Seniority Plus), (DME and Ostomy/Urology, TENS units for United Healthcare and UHCMC)** 
      8. Consult HMO Referral Guide, as appropriate for proper Vendor(s) by plan. 
      9. If provider puts Patient Request, MCR Reviewer should review prior to authorizing

    1st Level Review by Non Clinical Coordinator

    • Cataract-(66984) VA or BAT 20/50 or higher 
    • Therapeutic abortions (12 weeks or less – 59840/S0199) 
    • Hearing Aids (Basic model only)*: V5264, V5261 
    • Routine Eye Exams :92014 
    • Sterilization (BTL’s : 58600, 58605 
    • * Diabetic supplies* (Commercial plans must check with health plan to see if under 
    • pharmacy benefit, if so do not authorize) **not insulin pumps**: A4253, A4259, A4256, A4258 
    • Dialysis (Lupe): 90945, 90935 
    • Continued Dialysis (Lupe) : 90999 
    • Home Sleep Studies (Gladys, Cinthia, Jennifer): G0399, 95806, 95800, 95811 
    • Bras & Prosthesis (Intimate Image, Nobbe, Nordstrom, Birkholms, Althea’s—only if contracted to Health Plan) : L8000, L8020, L8030 
    • Radiation Therapy – SIM, SBRT, IMRT: 35 treatments and one F/U : 77373, 77263, 77280, 77290, 77295, 77293, G6015, 77014, 77338, 77301, 77300, 77334, 77417, 77336, 77427, 77470, 77370, 99213 
    • Contraceptive Device (J7300, J7298, J7307, J7297, 58300, 11981) 
    • Contracted Pediatric Specialists under age 18(Rheumatologist, Pulmonologist, Gastroenterologist, Neurology, Endocrinology, Cardiology, Nephrology, Hem/Onc) – Cinthia, Gladys, Lupe 

    2nd Level RN Review

    RN Reviewer or RN Case Manager may approve, if criteria is met; and utilizing clinical guidelines and Medicare, Health plan or Clinical Practice guidelines-Must be Clinic provider and must check work comp status or if provider indicated Patient request:

    • CT scan Guided Biopsy
    • D and C (elective)
    • TURP/ TURBT
    • BMT
    • Tonsillectomy
    • Appendectomy
    • Angiogram/Angioplasty
    • Continuing Radiation Therapy + one follow-up
    • Stereotactic Biopsy
    • Diabetic/Glaucoma/Cataract
    • Cholecystectomy
    • Hospital Elective Admission for surgery/chemo
    • Hernia repair
    • Out Patient Surgery (Done by Clinic Specialist)
    • Initial HME – Non standard equipment over $100
    • Podiatry (Non- routine foot care)
    • Diagnostic Studies/Labs
    • Extension of any outpatient short-term Rehabilitation (Beyond 60 days)
    • Rehabilitation Consult (Initial) (Continuing at Cottage Rehab Out pt)
    • Physical Therapy if meets criteria
    • Speech Therapy if criteria is met)
    • Occupational Therapy if criteria is met)
    • Physical Therapy at Dugan Therapy (assigned Country Clinic)
    • IV Therapy
    • Self -Injectable (Prescription Pharmacy)*BC/Aetna/Cigna/United Healthcare/Blue Shield/Health Net - Commercial
    • Oral Surgery/TMJ consults, if pt has not seen clinic ENT
    • CT/MRI (if Clinic can’t provide – example, MRI of Prostate at Cottage Hospital, 3D CT)
    • Cardiovascular Eval and F/U
    • Spinal/Back Eval
    • MOHS
    • Cottage Pediatric Specialists/ Concussion Clinic when Clinic Pediatrician refers
    • EEG
    • Myelogram
    • MBS (Barium Swallow)
    • Port Insertion/Removal
    • Bone Marrow Biopsy
    • Transfusion
    • Cardioversion
    • Circumcision
    • Any services Sansum Clinic can’t provide
    • Pediatric Care under age 18 Sansum doesn’t provide
    • Initial O2 (MCR guideline)
    • Lumpectomy
    • Capsulotomy
    • Hemorrhoidectomy
    • Bronchoscopy
    • Prosthesis estimate, if covered (need L codes)
    • Arthroscopies
    • Colonoscopy for all Clinic sites
    • DME and supplies (O2, CPAP, Wheel Chairs, Hosp. beds, Canes, Crutches, nebulizers.
    • Stat Labs/radiology ordered by PCP/Urgent Care provider
    • Hysterectomy/BSO
    • Ovarian Cystectomy
    • Excisional Biopsy

    3rd Level Review by MD

    Any possible denials

    • Tertiary center consult or hospitalization; surgery, or out patient surgeries 
    • Non-contracted provider referrals 
    • Any services and/or specialty, which are available and provided by Sansum Clinic, but patient wants service 
    • by another provider 
    • Pulmonary Rehabilitation 
    • Wound Care Center 
    • Not covered benefit 
    • Carve out 
    • Second opinions outside of Clinic, when another in clinic physician is available (possible AB-12 for Comm) 
    • Any appeal received in MCR Dept., letter needs to go to patient telling them it has been forwarded to the Health Plan, if Reviewer feels a mistake was made, they can ask committee to re-look at otherwise doesn’t need to go to subcommittee except for appearance in minutes as forwarded to health plan and so a letter can be generated to pt letting them know what we have done (do not need to do if they have indicated that they have cc healthplan already in their appeal) 
    • Chiropractic Care* 
    • Acupuncture (use Sansum Clinic Clinical Practice Guideline in absence of Health Plan criteria) 
    • Whole Breast Ultrasound for screening 
    • Genetic Testing 
    • Prosthesis, (once estimate received and items are verified to be Medicare coverable) 
    • Nuclear Medicine Studies (i.e. Bone, PET, and Pulmonary) 
    • any medical necessity determination that may potentially be denied when criteria is applied (i.e. Speech Therapy for children, Pterygiums (visual field ck), Orthotics (foot) if they do not have benefit, HME if they have benefit but do not meet criteria, other potential cosmetic denials, etc.) 
    • Hospital denials (prepared by Jamee/Michelle if already hospitalized) 
    • In Patient Rehab admission denials (reviewed by RN Case Manager and referred to Medical Director) 
    • Trauma admissions (Physician only-claims brings over to MCR Manager prior to Committee review) 
    • Any medically necessary denial for Home Health, DME, self- injectable, SNF (Michelle needs to prepare for Committee review) 
    • Transplant evaluation and Transplant Approvals 
    • Transgender 
    • Any Psych denial needs to be deferred to the mental health carve-out carrier. 
    • Experimental/Investigational care. 
    • Clinical Trial cases 
    • Complicated/high cost cases must be referred to Health Plan for their review, determination and response to member- if unsure if referral meets this criteria should be reviewed by Patient Care Subcommittee 

    MCR Coordinators must refer any questionable request to MCR Reviewer, RN Case Manager or MCR Manager. This list is reviewed annually and revised as necessary by MCR Manager.