Koa Mind, PLLC (“Koa Mind,” “we,” “us,” or “our”) is committed to providing clear information about the financial aspects of psychiatric care. This Financial Policy explains our approach to insurance, patient responsibility, payments, cancellations, and other financial matters.

By receiving services from Koa Mind, you acknowledge that you are responsible for understanding and complying with this policy and any financial terms provided to you before or during treatment.

1. INSURANCE

Koa Mind may participate with certain insurance plans directly or through third-party administrative and insurance platforms, including Headway.

Participation with an insurance plan does not guarantee that a particular service will be covered or that an insurance company will pay a particular amount.

Insurance benefits are determined by your individual health plan.

You are responsible for understanding your insurance coverage, including:

• Deductibles

• Copayments

• Coinsurance

• Out-of-network benefits

• Coverage limitations

• Prior authorization requirements

• Referral requirements

• Applicable exclusions

Koa Mind may assist with insurance billing and claims administration when applicable, but the final determination of coverage and payment is made by your insurance plan.

2. PATIENT FINANCIAL RESPONSIBILITY

Patients are responsible for amounts that are legally and contractually owed for services provided.

This may include applicable:

• Copayments

• Coinsurance

• Deductibles

• Non-covered services

• Services denied by an insurance plan

• Other patient responsibility amounts

If your insurance company does not pay for a service that you received, you may remain responsible for the applicable amount unless otherwise prohibited by law or your insurance agreement.

3. INSURANCE INFORMATION

Patients are responsible for providing accurate and current insurance information.

Please notify Koa Mind promptly if your:

• Insurance plan changes

• Member ID changes

• Coverage terminates

• Name changes

• Insurance becomes secondary or primary

• Other information relevant to billing changes

Failure to provide accurate insurance information may result in delays or claims being submitted incorrectly.

4. SELF-PAY SERVICES

Patients who do not use insurance, do not have insurance, or choose to pay privately may be treated as self-pay patients.

Koa Mind’s standard self-pay rate is $250 for initial session and $150 per standard session. Patients are responsible for payment of services provided.

Before services are provided, Koa Mind will communicate applicable fees and financial expectations. Self-pay patients will receive a Good Faith Estimate when required by applicable law.

5. GOOD FAITH ESTIMATES

Under applicable federal and state law, uninsured and self-pay patients may be entitled to a Good Faith Estimate of expected charges before receiving care.

Koa Mind will provide Good Faith Estimates as required by law. Estimates are based on information available at the time and are not guarantees of the final cost of care.

If you receive a bill that is substantially higher than your Good Faith Estimate, you may have rights under applicable law, including the federal patient-provider dispute resolution process.

6. PAYMENT

Payment arrangements will be communicated before or during the course of care.

Patients may be required to maintain a valid payment method on file where permitted and applicable.

Payments may be processed through Koa Mind, Headway, or another authorized payment or administrative platform.

Patients should review charges and statements promptly and contact Koa Mind regarding any billing questions.

7. COPAYMENTS, COINSURANCE, AND DEDUCTIBLES

If your insurance plan requires a copayment, coinsurance, or deductible, the applicable amount is generally due according to your insurance plan's requirements.

Koa Mind may collect applicable patient responsibility amounts at or around the time of service.

An insurance company's estimate of patient responsibility may not always equal the final amount determined after a claim is processed.

If the final insurance determination differs from the amount initially collected, your account may be adjusted accordingly.

8. INSURANCE CLAIMS AND DENIALS

Koa Mind may submit claims to insurance companies when appropriate.

Insurance claims may be denied, delayed, or processed differently than expected.

Common reasons may include:

• Eligibility issues

• Deductible requirements

• Coverage limitations

• Prior authorization requirements

• Coding or claim-processing issues

• Services determined not to be covered

• Incorrect or outdated insurance information

Patients are encouraged to contact their insurance company directly regarding coverage determinations and benefits.

Koa Mind may assist with reasonable billing or claim-related questions but cannot guarantee that an insurance company will approve or pay a claim.

9. OUT-OF-NETWORK CARE

If Koa Mind or a treating clinician is not in-network with your insurance plan, you may be responsible for amounts determined under your plan's out-of-network benefits.

Before receiving care, patients should confirm their benefits and understand their potential financial responsibility.

Koa Mind does not guarantee that a patient's insurance plan will reimburse out-of-network services.

10. CANCELLATIONS AND MISSED APPOINTMENTS

Appointments are reserved specifically for each patient. Patients must provide at least 24 hours’ notice to cancel or reschedule an appointment.

Cancellations made with less than 24 hours’ notice or missed appointments may be subject to a $75 fee, when permitted by law and applicable insurance requirements. This fee is the patient’s responsibility and will not be billed to insurance when prohibited or not covered.

Repeated late cancellations or missed appointments may affect the ability to schedule future appointments.

11. LATE ARRIVALS

Patients who arrive late to an appointment may receive a shortened appointment depending on clinician availability and clinical appropriateness. In some circumstances, a significantly late arrival may need to be rescheduled.

Any applicable cancellation or missed-appointment fee will be handled according to the applicable scheduling policy.

12. REFUNDS AND ACCOUNT CREDITS

If an account has an overpayment or credit balance, Koa Mind may apply the credit toward future eligible charges or issue a refund as appropriate.

Refunds will be processed in accordance with applicable law and payment-platform requirements.

13. CHANGES IN INSURANCE OR FINANCIAL CIRCUMSTANCES

Patients should notify Koa Mind if their insurance coverage or financial circumstances change.

A change in insurance may change the amount a patient is responsible for paying.

If you are unable to meet your financial obligations, please contact Koa Mind as soon as possible rather than allowing an unpaid balance to accumulate.

14. BILLING QUESTIONS AND DISPUTES

If you believe there is an error on a bill or statement, please contact Koa Mind promptly.

Billing questions should be directed to:

Koa Mind, PLLC
Email: info@koa-mind.com

Patients should provide relevant information regarding the charge in question so that the account can be reviewed.

Koa Mind will review billing concerns in good faith and make appropriate corrections when an error is identified.

15. UNPAID BALANCES

Patients are responsible for timely payment of valid amounts owed.

If a balance remains unpaid, Koa Mind may take reasonable collection steps permitted by law.

Before taking collection action, Koa Mind may provide notice regarding the outstanding balance and an opportunity to resolve the account.

Nothing in this policy permits Koa Mind to pursue collection activity that is prohibited by applicable law.

16. FINANCIAL ARRANGEMENTS AND PAYMENT PLANS

Payment plans may be considered on a case-by-case basis and are not guaranteed.

Any payment arrangement must be approved by Koa Mind in advance and may be subject to written terms.

A payment plan does not eliminate the underlying financial responsibility unless Koa Mind expressly agrees otherwise in writing.

17. PRESCRIPTIONS AND MEDICATION COSTS

Fees charged by Koa Mind generally relate to professional services and do not necessarily include the cost of medications.

Patients are responsible for prescription medication costs charged by pharmacies, including applicable:

• Copayments

• Deductibles

• Coinsurance

• Cash prices

• Other pharmacy charges

Koa Mind does not control pharmacy pricing, insurance coverage of medications, manufacturer pricing, or pharmacy dispensing decisions.

18. THIRD-PARTY PLATFORMS

Koa Mind may use third-party organizations, including Headway, to facilitate administrative, insurance, billing, scheduling, technology, or other practice functions.

Certain financial transactions or billing communications may therefore occur through a third-party platform.

Third-party services may have their own terms, payment policies, and procedures.

19. NO GUARANTEE OF INSURANCE PAYMENT

Koa Mind cannot guarantee that an insurance company will pay for any particular service.

Insurance benefits are ultimately determined by the patient's insurance plan.

Patients should contact their insurance company before receiving care if they have questions about:

• Coverage

• Deductibles

• Copayments

• Coinsurance

• Prior authorization

• Out-of-network benefits

• Medical necessity requirements
  
  

20. NO SURPRISES ACT

Koa Mind complies with applicable requirements of the federal No Surprises Act and related regulations.

The No Surprises Act provides certain protections for uninsured and self-pay individuals, including Good Faith Estimate requirements and, in qualifying circumstances, a patient-provider dispute resolution process.

Nothing in this Financial Policy is intended to waive rights provided to patients under the No Surprises Act or other applicable law.

21. CHANGES TO THIS POLICY

Koa Mind may update this Financial Policy periodically.

The current version will be made available to patients and may be posted on the Koa Mind website.

Changes to fees or financial requirements will be communicated as required by applicable law and before they become applicable to future services when appropriate.

22. CONTACT

Questions regarding this Financial Policy may be directed to:

Koa Mind, PLLC
Email: info@koa-mind.com
Website: koa-mind.com

Effective Date: October 2026