Commercial Insurance Primary, Medicare Secondary

Today's Date*

Patient Name*

First Last

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Phone*

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Email*

Clinic*

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 Primary

Name of Insurance Company

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

Co-insurance/co-pay for an exam/re-exam

% 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?

Chiropractic Maximum

Chiropractic maximum type per year

Amount of Chiropractic maximum

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-pay 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-pay 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?

Chiropractic Maximum

Chiropractic maximum type per year

Amount of Chiropractic maximum

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?

Medicare is Secondary

Clinic’s Participation Status

Participating provider with Medicare
Non-participating provider with Medicare

Medicare Deductible

How much deductible left to meet for this year?

Coordination of Benefits between the two insurances

Medicare 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 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.