Commercial Insurance Primary, Commercial Insurance Secondary

Tools > Insurance Verification Type > Commercial Insurance Primary, Commercial Insurance Secondary

Today's Date*
MM slash DD slash YYYY
Patient Name*
First Last
Hidden
Phone*
Hidden
Email*
Clinic*
Important Information
This patient has commercial insurance as primary, and commercial insurance as secondary. We will show the primary insurance’s benefits. We will show the secondary insurance’s benefits. We realize that these verifications are tricky to understand. If the patient hasn’t met their deductibles with both of the insurances, it would be a good idea to collect from them for deductible charges. After both insurances processes the claims, we will send a statement to the patient for their portion left due.
Commercial Insurance that is Primary
Name of the Commercial Insurance that is Primary
Clinic is
In Network Benefits
Individual Deductible
Amount per year
How much deductible left to meet for this year?
Deductible
Plan year runs from
Month/Day to Month/Day
Family Deductible
Amount per year
How much deductible left to meet for this year?
Insurance Benefits
Are the insurance benefits for spinal manipulations, exams, x-rays and therapies the same?
- Yes
- No
Co-insurance/co-pay that patient must pay per visit
After deductible is met:
% of the allowed in network rate?
Dollar amount?
Spinal Manipulations - After Deductible is Met
Co-insurance/co-pay for spinal manipulation
% of the allowed in network rate?
Dollar amount?
Exams/re-exams - After Deductible is Met
Exams/re-exams - After Deductible is Met
% of the allowed in network rate?
Dollar amount?
X-rays - After Deductible is Met
Co-insurance/co-pay for x-rays
% of the allowed in network rate?
Dollar amount?
Therapies - After Deductible is Met
Co-insurance/co-pay for a therapy
% of the allowed in network rate?
Dollar amount?
Co-insurance/co-pay for 97012 Mechanical Traction
% of the allowed in network rate?
Dollar amount?
Co-insurance/co-pay for 97110 Therapeutic Exercises
% of the allowed in network rate?
Dollar amount?
Chiropractic Maximum
Chiropractic maximum type per year
Amount of Chiropractic maximum
Amount of Chiropractic maximum
Amount of Chiropractic maximum left to use this year
Amount of Chiropractic maximum left to use this year
Pre-Authorization
Is pre-authorization required for chiropractic care?
- Yes
- No
If yes, what are the procedures for this?
Pre-authorization Information
Out of Network Benefits
Individual Deductible
Amount per year
How much deductible left to meet for this year?
Deductible
Plan year runs from
Month/Day to Month/Day
Family Deductible
Amount per year
How much deductible left to meet for this year?
Insurance Benefits
Are the insurance benefits for spinal manipulations, exams, x-rays and therapies the same?
- Yes
- No
Co-insurance/co-pays that patient must pay per visit
After deductible is met:
% of the charged amount?
Dollar amount?
Spinal Manipulations - After Deductible is Met
Co-insurance/co-pays for spinal manipulation
% of the charged amount?
Dollar amount?
Exams/re-exams - After Deductible is Met
Co-insurance/co-pay for an exam/re-exam
% of the charged amount?
Dollar amount?
X-rays - After Deductible is Met
Co-insurance/co-pay for x-rays
% of the charged amount?
Dollar amount?
Therapies - After Deductible is Met
Co-insurance/co-pay for a therapy
% of the charged amount?
Dollar amount?
Co-insurance/co-pay for 97012 Mechanical Traction
% of the charged amount?
Dollar amount?
Co-insurance/co-pay for 97110 Therapeutic Exercises
% of the charged amount?
Dollar amount?
Chiropractic Maximum
Chiropractic maximum type per year
Amount of Chiropractic maximum
Amount of Chiropractic maximum
Amount of Chiropractic maximum left to use this year
Amount of Chiropractic maximum left to use this year
Pre-Authorization
Is pre-authorization required for chiropractic care?
- Yes
- No
If yes, what are the procedures for this?
Commercial Insurance that is Secondary
Name of the Commercial Insurance that is Secondary
Clinic is
In Network Benefits
Individual Deductible
Amount per year
How much deductible left to meet for this year?
Deductible
Plan year runs from
Month/Day to Month/Day
Family Deductible
Amount per year
How much deductible left to meet for this year?
Insurance Benefits
Are the insurance benefits for spinal manipulations, exams, x-rays and therapies the same?
- Yes
- No
Co-insurance/co-pay that patient must pay per visit
After deductible is met:
% of the allowed in network rate?
Dollar amount?
Spinal Manipulations - After Deductible is Met
Co-insurance/co-pay for spinal manipulation
% of the allowed in network rate?
Dollar amount?
Exams/re-exams - After Deductible is Met
Exams/re-exams - After Deductible is Met
% of the allowed in network rate?
Dollar amount?
X-rays - After Deductible is Met
Co-insurance/co-pay for x-rays
% of the allowed in network rate?
Dollar amount?
Therapies - After Deductible is Met
Co-insurance/co-pay for a therapy
% of the allowed in network rate?
Dollar amount?
Co-insurance/co-pay for 97012 Mechanical Traction
% of the allowed in network rate?
Dollar amount?
Co-insurance/co-pay for 97110 Therapeutic Exercises
% of the allowed in network rate?
Dollar amount?
Chiropractic Maximum
Chiropractic maximum type per year
Amount of Chiropractic maximum
Amount of Chiropractic maximum
Amount of Chiropractic maximum left to use this year
Amount of Chiropractic maximum left to use this year
Pre-Authorization
Is pre-authorization required for chiropractic care?
- Yes
- No
If yes, what are the procedures for this?
Pre-authorization Information
Out of Network Benefits
Individual Deductible
Amount per year
How much deductible left to meet for this year?
Deductible
Plan year runs from
Month/Day to Month/Day
Family Deductible
Amount per year
How much deductible left to meet for this year?
Insurance Benefits
Are the insurance benefits for spinal manipulations, exams, x-rays and therapies the same?
- Yes
- No
Co-insurance/co-pays that patient must pay per visit
After deductible is met:
% of the charged amount?
Dollar amount?
Spinal Manipulations - After Deductible is Met
Co-insurance/co-pays for spinal manipulation
% of the charged amount?
Dollar amount?
Exams/re-exams - After Deductible is Met
Co-insurance/co-pay for an exam/re-exam
% of the charged amount?
Dollar amount?
X-rays - After Deductible is Met
Co-insurance/co-pay for x-rays
% of the charged amount?
Dollar amount?
Therapies - After Deductible is Met
Co-insurance/co-pay for a therapy
% of the charged amount?
Dollar amount?
Co-insurance/co-pay for 97012 Mechanical Traction
% of the charged amount?
Dollar amount?
Co-insurance/co-pay for 97110 Therapeutic Exercises
% of the charged amount?
Dollar amount?
Chiropractic Maximum
Chiropractic maximum type per year
Amount of Chiropractic maximum
Amount of Chiropractic maximum
Amount of Chiropractic maximum left to use this year
Amount of Chiropractic maximum left to use this year
Pre-Authorization
Is pre-authorization required for chiropractic care?
- Yes
- No
If yes, what are the procedures for this?
Additional Comments
Disclaimer
When we call on a patient's insurance and verify benefits, it is not a guarantee of payment by the insurance company and may vary according to the patient's individual plan when the actual claim is submitted. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service. The patient responsibility amount provided is an estimate of cost. The patient must understand that their health insurance company may deny payment for the services received. The patient must understand that it is ultimately the patient's responsibility to contact their insurance if they want to know exact chiropractic benefits.
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Commercial Insurance Primary, Commercial Insurance Secondary

Commercial Insurance that is Primary

In Network Benefits

Individual Deductible

Family Deductible

Insurance Benefits

Spinal Manipulations - After Deductible is Met

Exams/re-exams - After Deductible is Met

X-rays - After Deductible is Met

Therapies - After Deductible is Met

Chiropractic Maximum

Pre-Authorization

Out of Network Benefits

Individual Deductible

Family Deductible

Insurance Benefits

Spinal Manipulations - After Deductible is Met

Exams/re-exams - After Deductible is Met

X-rays - After Deductible is Met

Therapies - After Deductible is Met

Chiropractic Maximum

Pre-Authorization

Commercial Insurance that is Secondary

In Network Benefits

Individual Deductible

Family Deductible

Insurance Benefits

Spinal Manipulations - After Deductible is Met

Exams/re-exams - After Deductible is Met

X-rays - After Deductible is Met

Therapies - After Deductible is Met

Chiropractic Maximum

Pre-Authorization

Out of Network Benefits

Individual Deductible

Family Deductible

Insurance Benefits

Spinal Manipulations - After Deductible is Met

Exams/re-exams - After Deductible is Met

X-rays - After Deductible is Met

Therapies - After Deductible is Met

Chiropractic Maximum

Pre-Authorization