MedicaidStaff Forms » Chiropractic Insurance Verification » Medicaid"*" 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)StateChoose 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-pay $3.00Co-pay for exams/re-exams No co-pay $3.00Co-pay for x-rays No co-pay $3.00 per x-rayCo-pay for spinal manipulation No co-pay $1.00Co-pay for x-rays No co-pay $1.00 per x-rayAdditional InformationPatient 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. Therapies are not covered by Medicaid. Pre-authorization is not required.Additional InformationExams - 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 InformationExams - 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 Medicaid!Δ
