Insurance Policies Accepted at Vitruvian Surgical Institute

Dr. Carpenter is a participating Medicare provider. Patients are responsible for their usual copayments unless covered by a supplemental insurance policy. If you have commercial insurance or a secondary insurance policy like Medicaid, you are not responsible for the copays that Medicaid typically covers. Additionally, if you are enrolled in Medicare Advantage Plans, similar copayment responsibilities apply.

As a participating Medicare provider, Dr. Carpenter accepts payments from Medicare Advantage Plans. However, she is not specifically contracted with any particular Medicare Advantage Plan. Consequently, if your MAP is a PPO, it’s important to understand that your responsibility will depend on your insurance plan when it comes to out-of-network Medicare providers. On the other hand, if your MAP is an HMO, our team will need to take additional steps to obtain pre-authorization from either your primary care physician or your insurance plan to ensure your care with Dr. Carpenter is covered. Please make sure you have the necessary referrals, if required, before your appointment.

Dr. Carpenter is an out-of-network provider for commercial insurance plans, including Medicare and Medicare Advantage Plans. If your insurance plan is a PPO, your financial responsibility will be based on your plan’s guidelines for out-of-network providers. For those with an HMO or EPO, our team will assist you in navigating the additional steps required to obtain pre-authorization from your primary care physician or insurance plan to help ensure your care with Dr. Carpenter is covered. For electively scheduled cases, we will review Dr. Carpenter’s fee schedule with you in advance. Payment is collected prior to surgery, and our billing department will then submit your claim to your insurance. Each insurance carrier assigns a specific allowed amount for procedures; once your insurance processes and pays for the surgery, any reimbursement will be promptly returned to you. Please keep in mind that the allowed amount from your insurance carrier may not always cover the full extent of Dr. Carpenter’s fees. Our team is happy to address any questions you may have regarding your estimated out-of-pocket costs.

If Dr. Carpenter is an out-of-network (non-participating) provider with your commercial insurance plan, or if you have an HMO without out-of-network benefits, or a PPO with high out-of-network deductibles and copayments, you may be eligible to request a gap exception from your insurance carrier. This process can often help make your procedure more affordable by providing additional insurance coverage. A gap exception (also known as a clinical gap exception, out-of-network exception, or network insufficiency exception) is a request that your insurance company might approve on a case-by-case basis. This exception allows them to consider Dr. Carpenter’s services as if she were in-network when there are insufficient in-network providers available to meet your specific needs. If approved, your insurance would cover its typical allowed amount for a given procedure, and that insurance payment would be refunded to you, leaving you responsible only for the difference between that allowed amount and Dr. Carpenter's standard surgical fees.

Insurance carriers, including those under Medicare and Medicare Advantage Plans, are required by law to maintain adequate networks according to the Health Benefit Plan Network Access and Adequacy Act. This means that if there isn’t a suitable in-network plastic surgeon who can perform the necessary reconstructive care within a reasonable travel distance, wait time, or timeframe, your care may qualify for this exception. The procedure also must be medically necessary and a covered benefit under your plan. Common scenarios for which gap exceptions are granted include:

- The provider is the only specialist in the area offering a complex or rare procedure.

- The procedure takes place at a hospital or surgery center where no in-network physicians have privileges.

- The in-network options listed by the insurance company may not have the specialized skills, experience, or availability that best meet your needs.

Dr. Carpenter’s team is here to support you through this entire process. While you will need to initiate the request with your insurance carrier, our office and billing department are ready to assist you every step of the way by providing necessary clinical documentation, procedure codes, and other essential information. We are committed to guiding you and making the process as straightforward as possible. During the gap exception process, your insurance provider may require you to:

- Confirm that the procedure is a covered benefit under your plan.

- Obtain a referral from your primary care provider (if needed).

- Secure pre-certification or prior authorization for the procedure.

- Review the list of in-network providers to verify that no other qualified plastic surgeon is available within a reasonable distance or timeframe, or has privileges at your chosen facility.

Please understand that while we will do everything possible to help, there is no guarantee that your insurance carrier will approve the gap exception. Even if approved, it may not cover the full amount of Dr. Carpenter’s fees. Our team is always available to discuss your estimated out-of-pocket costs and address any questions you may have.

To help you get started, here is the necessary information:

- Provider name – Haley Carpenter, MD PhD

- NPI – 1740766641

- Office address – 2855 N University Drive, Suite 400, Coral Springs, FL 33065

- Tax ID / TIN – 99-2188017

- Office fax – 954-344-3781

- Office phone – 954-344-4344

- ICD-10 diagnosis code – ***

- Procedure code(s) – ***

- Expected date range of procedure – ***

- Insurance plan name – ***

- Patient member ID/Policy # – ***

- Patient phone number – ***

- Insurance reference number (provided by your carrier once the process begins) – ***

How to begin: Simply call your insurance carrier to request a gap exception for your planned procedure with Dr. Haley Carpenter. Provide them with the information above and any documentation they require. Be sure to ask for a reference or case number so you (and our team) can easily track your request. If you have any questions or would like our team to review your information before you call, please don’t hesitate to reach out. We’re here to help make this experience as smooth and stress-free as possible for you.