Financial Assistance

1. Steps for Insurance Claims

If you file claims with your insurance company to get reimbursements for your ACMA treatments, you will need to submit following two documents to your insurance company:

(a) Your Insurance Company’s Patient Reimbursement/Claim Form

This form is for patients who already made payments to the provider.  Please call your insurance company to get this form.  For your reference, following please find examples of two insurance company’s patient reimbursement claim forms.

Example: Blue Cross Blue Shield Patient Claim Form

Example: United Healthcare Patient Claim Form

(b) ACMA Claim Form/Receipt

Medicare and all insurance companies accept ACMA Claim Form as the receipt.  You need to attach ACMA Claim Form to your insurance company’s (or Medicare’s) patient claim form.  You can get ACMA Claim Form as follows:

ACMA Claim Form

Download the ACMA Claim Form

To download the ACMA Claim Form, please click


If you meet problems downloading above form, please try a different browser.

Most insurance companies accept black ink print of the form. Some insurance companies require color ink print of the form. Please follow your insurance company’s policy.


Steps to Complete the ACMA Claim Form
  • After each ACMA treatment, please attach above ACMA Claim Form to your insurance company’s Patient Claim Form.
  • To help your claim get approved, please complete the form as early as possible.
  • Each time, use one ACMA Claim Form for to file one of your ACMA treatment, and avoid submitting two or more ACMA treatments in one claim form.
  • Please use a notebook to keep track of your dates of service and payment amounts.
  • Although most insurance companies reimburse patients’ ACMA treatments back to one year ago, it is suggested to submit your claims as early as possible. Please do not wait until close to one year after your service date. This is because some patients delayed and submitted claims close to one year after their service date. Then their insurance companies returned the claims to them for them to correct code error or other issues. However, after they had corrected the code errors or other issues, the claims had passed the one year deadline from the service date, and could not be reimbursed any more. So the earlier to submit your claims the better.

How to Find Codes Correctly:

Many claim denials are because of errors or issues relating to the following two codes (Diagnosis Code and Procedure Code) in the above claim form. The following instructions can help you find the two codes correctly.

  • (A) Diagnosis Code
  • Many insurance companies require using different diagnosis code for each claim form. So please do not repeat the same diagnosis code in following claim forms. You will need to find as many diagnosis codes as possible to rotate.
  • Steps to Find the Diagnosis Codes:
    1. Go to following website:
      http://www.icd10data.com
    2. In the “Search” box, search all diseases and symptoms you have, one at a time. Many diseases and symptoms have multiple names. Please try all possible names.
    3. Click “Search”, and you will find many diagnosis codes for the disease or symptom.
    4. Please choose the diagnosis codes that meet following requirements:
      • The codes are ICD-10-CM instead of ICD-9-CM.
      • Specific — The codes are not “Unspecified”. The code should be specific, and does not contain the word “unspecified” in its definition.
      • Billable — The codes are billable (click the codes, and you will be able to find out whether the codes are billable or non-billable).
      • Green Arrow — Usually the Billable/Specific Code has a green arrow on the left side. So always choose the codes with green arrow on the left side.
    5. Rotate these codes for each claim form.
  • (B) Procedure/CPT Code
  • Please use following CPT codes for Procedure Code:
    1. CPT Code: 99205 for your first ACMA treatment.
    2. CPT Code: 99215 for all of your following ACMA treatments.

    If your insurance company requests you to use a different procedure code, please contact ACMA and we will resolve this issue for you.


Step IV. Submit Your New ACMA Claim Form

Please call your insurance company customer service to get the instruction on how to submit above claim form. Then follow their instruction to submit your claim form to your insurance company.

To help your claim be approved, please submit one claim each time, and avoid submitting two or more claims together.

After your claim is approved, your insurance company will reimburse you a check for your ACMA treatment cost based on your insurance plan coverage.


Step V. What To Do If Your Claim Is Denied

Insurance claim denial occurs frequently. For most cases, claim denial indicates that there are some problems in your claim form. After you correct the problems, your claim usually can be approved.

Based on many patient’s experiences, if your claim was denied, the following instruction can help your claim get finally approved:

  • In your claim denial letter, find out why your claim has been denied.
  • Then you can correct the errors or issues in one of following two ways: (1) Correct the errors or issues based on the original denied claim; (2) Re-submit a new claim by correcting the errors or issues without mentioning the previous denied claim.
  • Based on many patient’s experiences, avoid calling the insurance company. Just follow your insurance company’s written instructions will help your claims finally get approved. However, calling the insurance company, arguing with insurance company’s representatives, or filing appeals could cause your claims being permanently denied.

2. Steps for Medicare Claim

You will need following documents for Medicare claims:

(a) Medicare Patient Claim Form

Please call Medicare asking for the claim form that is used for patients who have already made payments to the provider.

(b) ACMA Claim Form

This form is accepted as a receipt and is required to be attached to above Medicare Patient Claim Form.  For more information on ACMA Claim Form, please see above Insurance Claim section.

Please follow Medicare’s instruction to complete and submit above two documents to Medicare.

3. Referral from Your Primary Care Doctor

ACMA is an out-of-network provider for most insurance companies.  Therefore, your reimbursements from your insurance company will be out-of-network provider reimbursements.

If you can get a referral letter from your primary care doctor or specialist to refer you to ACMA, you will get in-network reimbursements, which will have lower deductible and higher reimbursement rate.

Instruction on Medicare Patients

Medicare does not cover ACMA treatment, but many Medicare supplemental insurance companies cover ACMA treatment.

Following please find the documents needed to submit to your supplemental insurance companies:

To have a better chance to get your claim approved, please submit your claim to your supplemental insurance company instead of calling them over the phone.

4. Tax Benefits

If you want to get tax deductible benefits for your ACMA treatments, please follow the Tax Benefit Coverage instructions below.

Tax Benefit Coverage

The following tax plans cover ACMA treatments and ACMA cancer treatments. If you have any questions on following tax plans, please consult your accountant or contact IRS directly (IRS phone: 800-829-1040, website: www.irs.gov).

Flexible Spending Arrangement (FSA)

A Flexible Spending Arrangement (FSA; sometimes called a Flexible Spending Account) is a benefit provided by some employers that offers a way to help pay for out-of-pocket medical expenses, while reducing the employee’s taxable income.

With FSAs for health-related expenses, you choose an amount of pre-tax dollars to be set aside from your paycheck each pay period. This money is then available to reimburse certain health-related expenses that are not paid any other way, such as by insurance.

Health Savings Account (HSA)

Another type of tax-exempt benefit for health-related expenses is a health savings account (HSA). Set up by Congress in December 2003, HSAs allow some individuals who participate in a high-deductible health plan to save money in a tax-free account. If you are eligible, you can use these savings to pay for your future medical expenses or those of your spouse or dependents. The IRS has publications with more information about FSAs and HSAs. The Department of the Treasury also has a direct link to information about HSAs on its web site.

Cafeteria Plan

A cafeteria plan is a separate written plan maintained by an employer for employees that meets the specific requirements of and regulations of section 125 of the Internal Revenue Code. It provides participants an opportunity to receive certain benefits on a pretax basis. Participants in a cafeteria plan must be permitted to choose among at least one taxable benefit (such as cash) and one qualified benefit.

A qualified benefit is a benefit that does not defer compensation and is excludable from an employee’s gross income under a specific provision of the Code, without being subject to the principles of constructive receipt. Qualified benefits include:

  1. Accident and health benefits (but not Archer medical savings accounts or long-term care insurance);
  2. Health savings accounts, including distributions to pay long-term care services. The written plan must specifically describe all benefits and establish rules for eligibility and elections.

The plan may make benefits available to employees, their spouses and dependents. It may also include coverage of former employees, but cannot exist primarily for them.

Employer contributions to the cafeteria plan are usually made pursuant to salary reduction agreements between the employer and the employee in which the employee agrees to contribute a portion of his or her salary on a pre-tax basis to pay for the qualified benefits. Salary reduction contributions are not actually or constructively received by the participant. Therefore, those contributions are not considered wages for federal income tax purposes. In addition, those sums generally are not subject to FICA and FUTA. See Sections 3121(a)(5)(G) and 3306(b)(5)(G) of the Internal Revenue Code.

The above discussion provides only the most basic rules governing a cafeteria plan. For a complete understanding of the rules, see the Proposed Regulations under Code section 125.

Income Tax Deductible

Currently, the IRS allows deductibles for ACMA treatments in IRS Form 1040 return. You may claim your ACMA treatments as medical expenses in IRS Form 1040 return. If you have questions, your accountant may help you on this issue.