Name* Date* MM slash DD slash YYYY Getting the Most from Your InsuranceTo determine if you have behavioral health insurance coverage, you will need to call your insurance company and request the information outlined below for Eligibility & Benefits. PIP and MEDICARE patients do NOT need to call. Before calling, you may need a diagnosis from your therapist. Fill in the space below marked “diagnosis.” You will need your insurance identification card, a pen or pencil, and this form. Remember: You are the customer, you have the right to this information and to be treated politely and with patience. Begin by saying: “I am calling to find out what coverage my out of network benefits offer for a series of services provided by a licensed Nurse Practitioner.” If you already know, tell your insurance company what your diagnosis is or explain that you still need to find out: Diagnosis* After you answer all of the representative’s questions, ask, “To whom am I speaking?” Write down the representative’s Representative's Name* Representative's Phone, ext.* Ask: “Must I obtain a pre-authorization or a referral to be evaluated? Yes No PLEASE NOTE: You must first find out if you have out-of-network benefits. If you do, you need to then find out how much is your deductible and what is your co-insurance (percentage you will owe each visit). YOU ESPECIALLY NEED TO FIND OUT IF A “PRECERTIFICATION” IS REQUIRED AND REQUEST IT! You must request reimbursement checks be sent to the provider.New Patient intake InterviewAsk the representative: Is a diagnostic interview-(60 minutes) CPT code 99204 covered? Yes No Next, the representative will ask what procedures are going to be performed. If the representative does not ask, tell them that you have questions about the coverage for a number of procedures and that you have the codes for these procedures which are listed below.Medication Management with PsychotherapyAsk the representative: Is medication management (usually) CPT code 99214 covered? Yes No The code used will depend upon the complexity of the visit. As well as the psychotherapy portion, CPT codes 90833, 90836, 90837 or 90838? (These codes will be determined upon the amount of time used for therapy). How much of this is covered under my plan? Is there a maximum dollar amount for this service? Are authorizations required for any of these services? Yes No Now ask the representative:Are there any limitations on my coverage? What deductions must be satisfied before reimbursements are made? How much of my deductible has been satisfied to date? Do I have a copay or a co-insurance amount? Once again, ask for your representative’s Name: Once again, ask for your representative’s phone number: After ending the conversation, record Date: MM slash DD slash YYYY And Time : Hours Minutes AM PM AM/PM Then bring the completed form to our office. We will make a copy for our records. You should keep the original.NameThis field is for validation purposes and should be left unchanged.