Medicare Replacement Primary, Medicare Supplement Secondary

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Medicare Replacement Primary, Medicare Supplement Secondary

Note: This patient has a Medicare replacement plan as primary, and a Medicare supplement plan as secondary. The Medicare replacement plan takes the place of Medicare. We do not bill to Medicare. We bill to this Medicare replacement plan as primary.

Medicare Replacement Plan is Primary

Name of Insurance Company

Deductible per calendar year

How much deductible left to meet for this year?

Co-pay for Spinal Manipulation

Co-insurance for Spinal Manipulation

Additional Information

Exams/re-exams - not covered by Medicare Replacement Plan (but recommended to do on first visit of new diagnosis).
X-rays - not covered by Medicare Replacement Plan.
Therapies - not covered by Medicare Replacement Plan.
Chiropractic Maximum - no chiropractic maximum per year, but has to be medically necessary. Medicare Replacement Plan can do a records review if care goes on too long.
Pre-authorization - not required.

Note: The Medicare allowed amount for 98941 spinal manipulation is approximately $40. If the co-pay is more than $40, patient will only be responsible for approximately $40, the Medicare allowed amount for 98941 spinal manipulation. If the patient has a co-insurance due, the co-insurance will be based on the $40 Medicare allowed amount for 98941 spinal manipulation.

Medicare Supplement Plan is Secondary

Name of Insurance Company

Does this plan cover the patient’s Medicare Replacement Plan deductible?

Yes

There is no deductible for the Medicare Replacement Plan.

Does this plan cover the patient’s Medicare Replacement Plan co-pay?

Yes

There is no co-pay for the Medicare Replacement Plan.

Does this supplement plan follow the Wisconsin State Mandate?

Yes

Additional Information

Exams/re-exams - paid in full by Medicare Supplement Plan.
X-rays - paid in full by Medicare Supplement Plan.
Therapies - paid in full by Medicare Supplement Plan.
Chiropractic Maximum - no chiropractic maximum per year, but has to be medically necessary. Medicare can do a records review if care goes on too long.
Pre-authorization - not required.

Additional Information

Exams/re-exams - not covered by Medicare Supplement Plan (but recommended to do on first visit of new diagnosis). Patient responsibility.
X-rays - not covered by Medicare Supplement Plan. Patient responsibility.
Therapies - not covered by Medicare Supplement Plan. Patient responsibility.
Chiropractic Maximum - no chiropractic maximum per year, but has to be medically necessary. Medicare Supplement Plan can do a records review if care goes on too long.
Pre-authorization - not required.

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.