Financial Assistance
FINANCIAL ASSISTANCE POLICY
INcompass Healthcare offers financial assistance for care provided to eligible individuals and families. As a nonprofit health care organization, INcompass Healthcare is dedicated to supporting the patients and communities we serve through better health and better health care. The Financial Assistance Policy covers all INcompass Healthcare providers delivering emergency or medically necessary care in the hospital facility or in an outpatient office.
All patients are treated with respect and fairness. You may be eligible for assistance if you show you have financial need and provide our staff with necessary information regarding your income. Discounts will be based on household income and size. Discounts under this policy do not apply to co-insurance, deductibles, and co-payments, except where specifically noted.
APPLYING FOR FINANCIAL ASSISTANCE
You may apply for financial assistance at any time – before, during or after your care – up to 240 days after the first billing statement date.
To apply for Financial Assistance
- Fill out the Request for Financial Assistance Policy (FAP) Application form (Click here for the FAP Application Form)
- Include the supporting documents listed on the form
- Submit to the form and supporting documents to INcompass Healthcare staff who will determine your eligibility
If approved, financial assistance will be in effect for 12 months from the date of approval, or until your financial circumstances change, whichever comes first.
INCOME GUIDELINES FOR FINANCIAL ASSISTANCE
The amount of financial assistance you may receive is based upon Federal Poverty Level information established by U.S. government each year. In addition to your income, the discount will also consider your family size. (Click here for Subsidy Calculator)
Price Transparency
Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- Any patient may request an estimate of the expected charges for non-emergency health care services that have been ordered, scheduled, or referred and health care providers and facilities are required provide you with an estimate of the expected bill for medical items and services within 5 business days of the request.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
Click here for additional information related to your rights and protections against surprise medical bills.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
If you would like to receive an estimate, please contact our Billing Department at (812) 537 – 1302. Please be prepared to provide client name, date of birth, location of appointment, and specific service so that we are best able to estimate cost.
Charge Master
The Charge Master outlines the standard billable costs charged for services provided. Charges are the same for all patients, but a patient’s responsibility and out-of-pocket expenses (i.e. deductible, co-insurance, copays, etc.) may vary based upon insurance coverage and/or qualification for financial assistance. Patients can contact our Billing Department at (812) 537 – 1302 to determine whether they qualify for discounts. Please understand that few patients will pay the full charge amount listed due to insurance coverage and/or financial assistance discounts in place.
To view a copy of the current Charge Master, click here
For a PDF version, click here
| CODE | DESCRIPTION | |
| 5 | CLINICAL ASSESSMENT | |
| 9 | INDIVIDUAL THERAPY | |
| 10 | MARITAL/COUPLES THERAPY | $260.00/HOUR |
| 11 | FAMILY THERAPY | $260.00/HOUR |
| 12 | FAMILY SUPPORT GROUP | $25.00/EVENT |
| 13 | FAMILY GROUP THERAPY | $25.00/EVENT |
| 14 | GROUP PSYCHOTHERAPY | $136.40/EVENT |
| 16 | PEER SUPPORT SERVICES | $177.00/HOUR |
| 171 | SUD GROUP | $106.40/EVENT |
| 175 | IOP GROUP | $106.40/EVENT |
| 18 | PSYCHOLOGICAL INTERVIEW/TESTING | $120.00/HOUR |
| 19 | ANGER MANAGEMENT GROUP | $25.00/EVENT |
| 20 | FAMILY W/O PATIENT PRESENT | $260.00/HOUR |
| 21 | EMERGENCY SERVICES/DAYTIME | $100.00/HOUR |
| 22 | EMERGENCY SERVICES/AFTER HOURS | $200.00/HOUR |
| 24 | DBT GROUP | $136.40/EVENT |
| 25 | COACHING DBT | NO RATE |
| 30 | SSA CHILD MSE | $148.00/EVENT |
| 31 | SSA ADULT MSE | $148.00/EVENT |
| 32 | SSA WAIS IV | $125.00/EVENT |
| 33 | SSA WISC IV | $125.00/EVENT |
| 34 | SSA BAYLEY | $160.00/EVENT |
| 35 | SSA STANFORD BINET V | $140.00/EVENT |
| 36 | SSA WPPSI | $95.00/EVENT |
| 37 | SSA WMS IV | $200.00/EVENT |
| 38 | SSA VINELAND ADAPT | $160.00/EVENT |
| 39 | AT RISK ASSESSMENT | $65.00/HOUR |
| 50 | HB FAM CENTERED THERAPY | $98.40/HOUR |
| 51 | DCS HOME BASED ASSESSMENT | $80.00/HOUR |
| 52 | DCS REPORT | $78.76/HOUR |
| 53 | PARENT EDUCATION GROUP | $25.00/GROUP |
| 54 | HOMEMAKER SERVICES | $54.36/HOUR |
| 55 | PARENT EDUCATION INDIVIDUAL | $80.32/HOUR |
| 56 | PARENTING/FAM FUNCT ASSESS | $68.40/HOUR |
| 57 | HB FAM CENTER CASEWK SUPER VISIT | $79.32/HOUR |
| 58 | VISIT FACILITAT P/C/S SUPERVISED VIS | $54.36/HOUR |
| 59 | COUNSELING SUPERVISED VISITATION | $67.12/HOUR |
| 60 | HOMEMAKER SUPERVISED VISITATION | $54.36/HOUR |
| 61 | HB FAM CASEWORK FACE TO FACE | $79.32/HOUR |
| 62 | HB FAM CEN THERAPY SUP VISITATION | $98.36/HOUR |
| 63 | CARE NETWORK | $60.00/HOUR |
| 64 | DCS COUNSELING TEAM MTG | $64.00/HOUR |
| 65 | DCS WRAPAROUND PER DIEM | $965.49/EVENT |
| 66 | COUNSELING THERAPY | $68.40/HOUR |
| 67 | RECOVERY COACH | $80.00/HOUR |
| 68 | PRESERVATION PER DIEM | $113.47/EVENT |
| 69 | PRESERVATION WEEKLY SAFETY CK | $0.00 |
| 70 | PRESERVATION CONTACT TRACKING | $0.00 |
| 71 | PRESERVATION CHILD PER DIEM | $24.50/EVENT |
| 72 | PRESERVATION MONTHLY MEETING | $0.00 |
| 250 | WRAPAROUND FACILITATION | $115.00/HOUR |
| 251 | WRAPAROUND TECHNICIAN | $104.56/HOUR |
| 252 | HABILITATION | $85.60/HOUR |
| 253 | RESPITE CARE | $16.00/HOUR |
| 254 | CRISIS RESPITE | $15.00/HOUR |
| 255 | NON-MEDICAID TRANSPORATION | $5.00/ONE WAY TRIP |
| 256 | THERAPEUTIC SERVICES | $90.00/HOUR |
| 257 | TRAINING AND SUPPORT | $60.00/HOUR |
| 258 | FLEX FUNDS | $ FOR $ |
| 331 | INITIAL HOSPITAL CONSULT | $165.00/HOUR |
| 336 | SUBSEQUENT HOSPITAL CONSULT | $165.00/HOUR |
| 361 | IPU PHYSICAL | $125.00/EVENT |
| 366 | IPU PHYSICAL FOLLOW UP | $60.00/EVENT |
| 381 | INITIAL IPU PHYSICIAN ROUND | $85.00/EVENT |
| 382 | INITIAL IPU PHYSICIAN ROUND | $140.00/EVENT |
| 383 | INITIAL IPU PHYSICIAN ROUND | $190.00/EVENT |
| 391 | SUBSEQUENT IPU PHYSICIAN ROUND | $45.00/EVENT |
| 392 | SUBSEQUENT IPU PHYSICIAN ROUND | $75.00/EVENT |
| 393 | SUBSEQUENT IPU PHYSICIAN ROUND | $100.00/EVENT |
| 41 | INPATIENT DAY OF CARE | $1000.00/EVENT |
| 42 | THERAPEUTIC LEAVE DAY | $85.00/EVENT |
| 43 | ISOLATION MONITORING | $45.00/HOUR |
| 490 | MEDICINAL SUPPLIES | COST* |
| 491 | PHARMACY SERVICES | COST* |
| 492 | LABORATORY SERVICES | COST* |
| 493 | RADIOLOGY SERVICES | COST* |
| 494 | ELECTROCARDIOLOGY SERVICES | COST* |
| 495 | RESPIRATORY THERAPY | COST* |
| 496 | PHYSICAL THERAPY | COST* |
| 497 | NUCLEAR MEDICINE SERVICES | COST* |
| 499 | OTHER HOSPITAL SERVICES | COST* |
| 9500 | FACILITY CHG FOR SERVICE 05 | $146.88/EVENT |
| 9501 | FACILITY CHG FOR SERVICE 09 1/2 HR | $146.88/EVENT |
| 9502 | FACILITY CHG FOR SERVICE 09 1 HR | $146.88/EVENT |
| 9503 | FACILITY CHG FOR SERVICE 09 1 1/2 HR | $146.88/EVENT |
| 9504 | FACILITY CHG FOR SERVICE 10 | $100.00/EVENT |
| 9505 | FACILITY CHG FOR SERVICE 11 | $100.00/EVENT |
| 9506 | FACILITY CHG FOR SERVICE 13 | $50.00/EVENT |
| 9507 | FACILITY CHG FOR SERVICE 14 | $73.44/EVENT |
| 9508 | FACILITY CHG FOR SERVICE 20 | $100.00/EVENT |
| 9509 | FACILITY CHG FOR SERVICE 171/175 | $71.40/EVENT |
| 9510 | FACILITY CHG FOR SERVICE 311 | $60.00/EVENT |
| 9511 | FACILITY CHG FOR SERVICE 16 | $146.88/EVENT |
| 9600 | FACILITY CHG FOR SERVICE 99201 | $146.88/EVENT |
| 9601 | FACILITY CHG FOR SERVICE 99202 | $146.88/EVENT |
| 9602 | FACILITY CHG FOR SERVICE 99203 | $146.88/EVENT |
| 9603 | FACILITY CHG FOR SERVICE 99204 | $146.88/EVENT |
| 9604 | FACILITY CHG FOR SERVIC E 99205 | $146.88/EVENT |
| 9605 | FACILITY CHG FOR SERVICE 99211 | $146.88/EVENT |
| 9606 | FACILITY CHG FOR SERVICE 99212 | $146.88/EVENT |
| 9607 | FACILITY CHG FOR SERVICE 99213 | $146.88/EVENT |
| 9608 | FACILITY CHG FOR SERVICE 99214 | $146.88/EVENT |
| 9609 | FACILITY CHG FOR SERVICE 99215 | $146.88/EVENT |
| 9610 | FACILITY CHG FOR SERVICE 99495 | $100.00/EVENT |
* Actual charge for supplies/services received
| CODE | DESCRIPTION | RATE |
| 100 | MRO LON DETERMINATION | $77.72/EVENT |
| 101 | MRO INDIVIDUAL COUNSELING | $114.60/HOUR |
| 102 | MRO GROUP COUNSELING | $28.64/HOUR |
| 103 | MRO FAMILY WITH CONSUMER | $114.60/HOUR |
| 104 | MRO FAMILY WITHOUT CONSUMER | $114.60/HOUR |
| 105 | MRO FAMILY GROUP WITH CONSUMER | $28.64/HOUR |
| 106 | MRO FAMILY GROUP W/O CONSUMER | $28.64/HOUR |
| 107 | MRO MED TRAINING AND SUPPORT | $74.48/HOUR |
| 108 | MRO MED TRAINING GROUP | $13.40/HOUR |
| 109 | MRO MED TRAINING FAMILY | $74.48/HOUR |
| 110 | MRO MED TRAIN FAM GRP W/O CON | $13.40/HOUR |
| 111 | MRO MED TRAIN FAM WITH CON | $84.48/HOUR |
| 112 | MRO MED TRAIN FAM GRP WITH CON | $13.40/HOUR |
| 113 | MRO SKILLS TRAINING AND DEV IND | $104.56/HOUR |
| 114 | MRO SKILLS TRAINING GROUP | $18.84/HOUR |
| 115 | MRO SKILLS TRAIN FAMILY W/O CON | $104.56/HOUR |
| 116 | MRO SKILLS TRAIN FAM GRP W/O CONS | $18.84/HOUR |
| 117 | MRO SKILLS TRAIN FAMILY WITH CON | $104.56/HOUR |
| 118 | MRO SKILLS TRAIN FAM GRP WITH CON | $18.84/HOUR |
| 119 | MRO CASE MANAGEMENT | $58.12/HOUR |
| 120 | MRO CRISIS INTERVENTION | 134.88/HOUR |
| 121 | MRO PSYCH INTERVENT FACE TO FACE | $122.48/HOUR |
| 122 | MRO PSYCH INTERVENT NON FACE TO | $73.48/HOUR |
| 123 | MRO CAIRS | $58.48/HOUR |
| 124 | MRO AIRS | $58.48/HOUR |
| 125 | MRO INTENSIVE OUTPATIENT | $174.96/3 HOUR |
| 126 | MRO ADDICTION COUNSELING IND | $58.32/HOUR |
| 127 | MRO ADDICT FAMILY WITH CON | $58.32/HOUR |
| 128 | MRO ADDICT FAMILY W/O CON | $14.58/HOUR |
| 129 | MRO ADDICTION GROUP | $14.58/HOUR |
| 130 | MRO ADDICT FAM GROUP WITH CON | $14.58/HOUR |
| 131 | MRO ADDICT FAM GROUP W/O CON | $14.58/HOUR |
| 132 | MRO PEER RECOVERY SERVICES | $34.20/HOUR |
| 133 | MRO PSYCH INTERVENT – APN | $122.48/HOUR |
| 134 | MRO PSYCH INTERVENT – APN NON FTF | $73.48/HOUR |
| 135 | MRO SKILLS TRN SUPERVISED VISIT | $104.56/HOUR |
| 136 | BPHC Care Coordination | $58.12/HOUR |
| 142 | PRIME FOR LIFE | 260.00/EVENT |
| 580 | SCREENING/PRE-VOCATIONAL REFERRAL | $0.00 |
| 581 | DISCOVERY | $42.00/HOUR |
| 582 | WORK EXPERIENCE DEVELOPMENT | $42.00/HOUR |
| 583 | WORK EXPERIENCE A 1-5 HOURS/WEEK | $200.00/WEEK |
| 584 | WORK EXPERIENCE B 6-10 HOURS/WEEK | $325.00/WEEK |
| 585 | WORK EXPERIENCE C 11+ HOURS/WEEK | $450.00/WEEK |
| 586 | JOB READINESS TRAINING | $42.00/HOUR |
| 587 | JOB SEARCH AND PLACEMENT ASSISST | $42.00/HOUR |
| 588 | EMPLOYMENT MILESTONE 1 | $1300.00/EVENT |
| 589 | EMPLOYMENT MILESTONE 2 | $1500.00/EVENT |
| 590 | EMPLOYMENT MILESTONE 3 | $1300.00/EVENT |
| 591 | ON THE JOB SUPPORTS SHORT TERM | $42.00/HOUR |
| 592 | SUPPORT EMPLOYMENT 1-5 HRS/MTH | $176.00/MONTH |
| 593 | SUPPORT EMPLOYMENT 6-10 HRS/MTH | $352.00/MONTH |
| 594 | SUPPORT EMPLOYMENT 11-15 HRS/MTH | $528.00/MONTH |
| 595 | SUPPORT EMPLOYMENT 16-20 HRS/MTH | $720.00/MONTH |
| 596 | SUPPORT EMPLOYMENT 21-25 HRS/MTH | $920.00/MONTH |
| 597 | SUPPORT EMPLOYMENT 26-30 HRS/MTH | $1120.00/MTH |
| 598 | SUPPORTED EMPLOYMENT HOURLY | $42.00/HOUR |
| 599 | BENEFITS ANALYSIS | $500.00/EVENT |
| 600 | LEVEL OF CARE CONSULTATION | $100.00/HOUR |
| 601 | COMPETENCY EVALUATION | $100.00/HOUR |
| 602 | ADHD EVALUATION | $97.00/HOUR |
| 603 | WALK IN CLINIC EVALUATION | $240.00/HOUR |
| 604 | BARIATRIC EVALUATION | $100.00/HOUR |
| 605 | MEDICAID DISABILITY EVALUATION | $80.00/HOUR |
| 606 | SOCIAL SECURITY DISABILITY EVAL | $100.00/EVENT |
| 607 | STERLING EVALUATION | $93.48/HOUR |
| 608 | PARENTING ASSESSMENT | $97.00/HOUR |
| 609 | JAIL CONSULTS | $100.00/HOUR |
| 610 | PASARR EVALUATION | $100.00/HOUR |
| 611 | DRUG AND ALCOHOL EVALUATION | $100.00/EVENT |
| 80 | TELEPHONE EMERGENCIES | $0.00 |
| 83 | INTERN TRACKING | $0.00 |
| 84 | TESTIMONY/DEPOSITION | $200.00/EVENT |
| 85 | BRIDGE DEVICE | $800.00/EVENT |
| 88 | INTERPRETER SERVICES | $75.00/HOUR |
| 89 | DRUG TESTING | $15.00/EVENT |
| 95 | INFORMATION/REFERRAL | $0.00 |
| 96 | DOCUMENTATION ONLY | $0.00 |
| 3410 | RN STAFF EDUCATION | $0.00 |
| 3411 | RN MEDICATION AUDIT | $0.00 |
| 3412 | RN CONSULTATION | $0.00 |
| 3413 | RN TB TESTING | $0.00 |
| 99201 | NEW PATIENT STRAIGHTFORWARD | $178.88/EVENT |
| 99202 | NEW PATIENT EXPANDED | $200.88/EVENT |
| 99203 | NEW PATIENT DETAILED | $231.88/EVENT |
| 99204 | NEW PATIENT COMPREHENSIVE | $276.88/EVENT |
| 99205 | NEW PATIENT HIGH COMPLEXITY | $326.88/EVENT |
| 99211 | ESTABLISHED PATIENT MINIMAL COMPLEX | $162.88/EVENT |
| 99212 | ESTABLISHED PATIENT STRAIGHTFORWARD | $191.88/EVENT |
| 99213 | ESTABLISHED PATIENT LOW COMPLEX | $216.88/EVENT |
| 99214 | ESTABLISHED PATIENT MODERATE | $246.88/EVENT |
| 99215 | ESTABLISHED PATIENT HIGH COMPLEX | $286.88/EVENT |
| 99216 | SMOKING CESSATION | $15.00/EVENT |
| 99495 | TRANSITIONAL CARE EVALUATION | $262.80/EVENT |
| T9201 | TELEHEALTH NEW PT STRAIGHTFORWARD | $178.88/EVENT |
| T9202 | TELEHEALTH NEW PT EXPANDED | $200.88/EVENT |
| T9203 | TELEHEALTH NEW PT DETAILED | $231.88/EVENT |
| T9204 | TELEHEALTH NEW PT COMPREHENSIVE | $276.88/EVENT |
| T9205 | TELEHEALTH NEW PT HIGH COMPLEXITY | $326.88/EVENT |
| T9211 | TELEHEALTH ESTAB PT MINIMAL COMPLEX | $162.88/EVENT |
| T9212 | TELEHEALTH ESTAB PT STRAIGHTFORWARD | $191.88/EVENT |
| T9213 | TELEHEALTH ESTAB PT LOW COMPLEX | $216.88/EVENT |
| T9214 | TELEHEALTH ESTAB PT MODERATE | $246.88/EVENT |
| T9215 | TELEHEALTH ESTAB PT HIGH COMPLEXITY | $286.88/EVENT |
| T3014 | TELEHEALTH SPOKE SITE | $35.00/EVENT |
| 69290 | EAR IRRIGATION | $15.00/EVENT |
| 82948 | GLUCOSE | $15.00/EVENT |
| 96372 | IM INJECTION | $25.00/EVENT |
| 87804 | RAPID FLU SWAB | $20.00/EVENT |
| 87880 | RAPID STREP | $20.00/EVENT |
| 81025 | URINE PREGNANCY | $10.00/EVENT |
| 99364 | VENIPUNCTURE | $10.00/EVENT |
FAQ’s
What forms of payment are accepted?
We accept cash, personal checks, money orders, FSA, HRA, HSA, debit card, as well as VISA, MasterCard, Discover, and American Express.
Will you accept my insurance plan?
We accept the majority of the insurance providers in our area including Medicaid, Healthy Indiana Plan (HIP), and Medicare; however, please contact your insurance provider to see if we are in your network. On the front or the back of your insurance card you will find a phone number that will allow you to contact your insurance provider directly to determine if we are in or out of network.
Will any of my services not be covered by insurance?
It is your primary responsibility to contact your insurance provider to make sure the services you are receiving will be covered by insurance. You will want to make sure both the service and the provider you are seeing are covered by your insurance plan.
What if I don’t have insurance?
We will evaluate and treat anyone who is experiencing a medical emergency, regardless of your ability to pay. For clients without insurance, we will assist you with obtaining coverage, if eligible. At the first visit, we can assist you with applying for presumptive eligibility. If approved, this will provide temporary coverage. We can also assist with the full application to receive Medicaid benefits.
Do you offer any form of financial assistance?
We have a Finance Assistance program to help individuals in need of service who are not otherwise able to afford care.
When or will I receive a statement for services?
We process client statements monthly. Typically, you will receive a statement by the middle of the month for the previous months’ services if an amount is due. If you have insurance coverage, you will receive a statement after the claim has been processed with your insurance provider. The amount of time for processing varies by provider. You will continue to receive a monthly statement until your balance paid in full. If not paid in full after 3 statements or arrangements have not been made with Billing department, the account is referred to outside vendor for collections.