Insurance Primary, Medicaid SecondaryStaff Forms » Chiropractic Insurance Verification » Insurance Primary, Medicaid Secondary"*" indicates required fieldsToday'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 Burr RidgeWW CoralvilleWW Eau ClaireWW Eden PrairieWW 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 InformationPatient has a commercial insurance as primary, and Medicaid as secondary. We will show the regular benefits with patient’s commercial insurance, but understand the following:If patient’s care goes to the commercial insurance’s deductible, Medicaid will cover the charge at the Medicaid allowed amount (for spinal manipulations, and for exam and x-rays on first visit of diagnosis).If patient has co-insurance or a co-pay due with commercial insurance, we will follow the co-pay amount for Medicaid instead.If patient has a chiropractic maximum with commercial insurance, we will follow the chiropractic maximum for Medicaid instead.Primary InsuranceName of Insurance CompanyClinic 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/DayFamily 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 NoCo-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/No 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?Co-insurance/co-pay for 97012 Mechanical TractionChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay dueNot a covered service% of the allowed in network rate?Dollar amount?Co-insurance/co-pay for 97110 Therapeutic ExercisesChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay dueNot a covered service% 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 NoIf 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/DayFamily 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 NoCo-insurance/co-pay that patient must pay per visitAfter deductible is met:Choose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insuance/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 MetCo-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?Co-insurance/co-pay for 97012 Mechanical TractionChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay dueNot a covered service% of the charged amount?Dollar amount?Co-insurance/co-pay for 97110 Therapeutic ExercisesChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay dueNot a covered service% 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 NoIf yes, what are the procedures for this?Secondary Insurance - MedicaidStateChoose OneWisconsinMinnesotaMichiganDeductibleCo-pay for spinal manipulation No co-pay $1.00 for 98940 $2.00 for 98941Co-pay for exams/re-exams No co-pay $1.00Co-pay for x-rays No co-pay $3.00 per x-rayCo-pay for spinal manipulation No co-payCo-pay for exams/re-exams No co-payCo-pay for x-rays No co-payCo-pay for spinal manipulation No co-payCo-pay for x-rays No co-payAdditional Information Therapies - Not covered by Medicaid Chiropractic Maximum - 20 visits per diagnosis Pre-authorization - Not required Patient has regular Medicaid coverage. Exams and X-rays (up to 3) are covered on the first visit of diagnosis. Then only 98940 or 98941 is covered after that. Medicaid allows 20 visits per diagnosis. A new diagnosis can be done after 20 visits if more care is needed. When a new diagnosis is done, an exam and x-rays can be charged if they are performed on that initial visit of diagnosis.Additional Information Exams - 1 exam allowed per year. Has to be on the first visit of diagnosis. X-ray - 1 x-ray allowed per year. Has to be on the first visit of diagnosis. Therapies - Not covered by Medicaid. Chiropractic Maximum - 24 visits per year (no more than 6 visits per month). Pre-authorization - Not required.Additional Information Exams - Not covered by Medicaid. Cannot charge patient for this. Therapies - Not covered by Medicaid. Cannot charge patient for this. X-ray - 1 x-ray allowed per year. Chiropractic Maximum - 18 visits per year. Pre-authorization - Not required.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.Need help understanding this document? Watch this short video on Insurance Primary, Medicaid Secondary!Δ
