Commercial Insurance Primary, Medicare Secondary Tools > Insurance Verification Type > Commercial Insurance Primary, Medicare Secondary Today's Date* MM slash DD slash YYYY Patient Name* First Last HiddenPhone*HiddenEmail* Clinic*Choose a ClinicBalanced Living ChiropracticCoulee HealthErickson ChiropracticHendricks ChiropracticHome Team ChiropracticHonchel ChiropracticKaizen ChiropracticModern Spine Health (Richard Wilson)Nemitz ChiropracticRestore Spine and Wellness (Mequon)Revive ChiropracticTruhlsen ChiropracticTruhlsen Chiropractic-HendricksWeber ChiropracticWW AppletonWW BeavertonWW BismarckWW BloomingtonWW Burr RidgeWW Eau ClaireWW FitchburgWW Flathead ValleyWW Fort MillWW Grand RapidsWW Grass ValleyWW Green BayWW JacksonvilleWW Lake MaryWW LargoWW LouisvilleWW MariettaWW North PhoenixWW PensacolaWW RaleighWW South JordanWW SpringWW SteubenvilleWW St CloudWW St PetersWW WaukeshaWW Wesley ChapelWW Woodbury (Empower Health)Important Information This patient has Commercial Insurance as primary, and Medicare as secondary. We will show the Commercial Insurance benefits. We will show the Medicare benefits. We will show how the Commercial Insurance will coordinate with Medicare.Commercial Insurance that is PrimaryName of Insurance Company Clinic isChooseIn NetworkOut of NetworkIn Network BenefitsIndividual DeductibleAmount per yearHow much deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/Day Family DeductibleAmount per yearHow much deductible left to meet for this year?Insurance BenefitsAre the insurance benefits for spinal manipulations, exams, x-rays and therapies the same? Yes No Co-insurance/co-pay that patient must pay per visitAfter deductible is met:Choose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurace/co-pay due% of the allowed in network rate? Dollar amount?Spinal Manipulations - After Deductible is MetCo-insurance/co-pay for spinal manipulationChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate? Dollar amount?Exams/re-exams - After Deductible is MetCo-insurance/co-pay for an exam/re-examChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate? Dollar amount?X-rays - After Deductible is MetCo-insurance/co-pay for x-raysChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate? Dollar amount?Therapies - After Deductible is MetCo-insurance/co-pay for a therapyChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate? Dollar amount?Chiropractic MaximumChiropractic maximum type per yearChooseVisit limitDollar amount limitNo chiropractic maximum per year, but has to be medically necessary.Amount of Chiropractic maximumAmount of Chiropractic maximumAmount of Chiropractic maximum left to use this yearAmount of Chiropractic maximum left to use this yearPre-AuthorizationIs pre-authorization required for chiropractic care? Yes No If yes, what are the procedures for this?ChooseProvider needs to submit clinical submission form to insurance.Pre-authorization informationPre-authorization InformationOut of Network BenefitsIndividual DeductibleAmount per yearHow much deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/Day Family DeductibleAmount per yearHow much deductible left to meet for this year?Insurance BenefitsAre the insurance benefits for spinal manipulations, exams, x-rays and therapies the same? Yes No Co-insurance/co-pay that patient must pay per visitAfter deductible is met:Choose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount? Dollar amount?Spinal Manipulations - After Deductible is MetCo-insurance/co-pay for spinal manipulationChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount? Dollar amount?Exams/re-exams - After Deductible is MetCo-insurance/co-pay for an exam/re-examChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount? Dollar amount? X-rays - After Deductible is Met Co-insurance/co-pay for x-raysChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount? Dollar amount?Therapies - After Deductible is MetCo-insurance/co-pay for a therapyChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount? Dollar amount?Chiropractic MaximumChiropractic maximum type per yearChooseVisit limitDollar amount limitNo chiropractic maximum per year, but has to be medically necessary.Amount of Chiropractic maximumAmount of Chiropractic maximumAmount of Chiropractic maximum left to use this yearAmount of Chiropractic maximum left to use this yearPre-AuthorizationIs pre-authorization required for chiropractic care? Yes No If yes, what are the procedures for this?Medicare is SecondaryClinic’s Participation Status Participating provider with Medicare Non-participating provider with Medicare Medicare Deductible Medicare Deductible How much deductible left to meet for this year?Coordination of Benefits between the two insurancesMedicare does not cover exams, x-rays, or therapies. Any exams, therapies, or x-rays performed will be covered at the benefit listed for the primary commercial insurance. If the spinal manipulation goes to both the commercial insurance deductible and the Medicare deductible, the patient will owe at the most approximately $40 for a visit. If the spinal manipulation goes to the commercial insurance deductible but the Medicare deductible is already met, then the patient will owe between $5.00 and $8.00 for a spinal manipulation. Complete coordination of benefits cannot be determined exactly until claims are processed with both insurances.Additional CommentsDisclaimer 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. Δ