Diagnostic Commercial and Medicaid Managed Care Plan Today's Date* MM slash DD slash YYYY Patient Name* First Last HiddenPhone*HiddenEmail* Clinic*Choose a ClinicDreamShip CenterMilestones Behavioral PediatricsTrio AcademyPrimary Insurance CoverageName of Insurance Company Insurance ID #* Clinic isChooseIn NetworkOut of NetworkInsurance Coverage for these codes: 90791 Diagnostic Interview 96136 Psychological Testing (1st 30 minutes) 96137 Psychological Testing (additional 30 minutes) 96130 Psychological Testing Evaluation (1st 30 minutes) 96131 Psychological Testing Evaluation (additional 30 minutes)In Network BenefitsIndividual Deductible - Amount per yearHow much individual deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/Day Family Deductible - Amount per yearHow much family deductible left to meet for this year?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 dueCo-insurance - % of the allowed in network rate? Co-pay - Dollar amount?Individual Out of Pocket - Amount per yearOnce a patient has met their out of pocket for the year, the patient's co-pay or co-insurance will no longer apply.How much individual out of pocket left to meet for this year?Family Out of Pocket - Amount per yearOnce a patient has met their out of pocket for the year, the patient's co-pay or co-insurance will no longer apply.How much family out of pocket left to meet for this year?Is prior authorization required for diagnostic services with this primary insurance? Yes No Out of Network BenefitsIndividual Deductible - Amount per yearHow much indvidual deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/Day Family Deductible - Amount per yearHow much family deductible left to meet for this year?Co-insurance/co-pays that patient must pay per visitAfter deductible is met:Choose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/No co-pay dueCo-insurance - % of the charged amount? Co-pay - Dollar amount?Individual Out of Pocket - Amount per yearOnce a patient has met their out of pocket for the year, the patient's co-pay or co-insurance will no longer apply.How much individual out of pocket left to meet for this year?Family Out of Pocket - Amount per yearOnce a patient has met their out of pocket for the year, the patient's co-pay or co-insurance will no longer apply.How much family out of pocket left to meet for this year?Is prior authorization required for diagnostic services with this primary insurance? Yes No Secondary Insurance CoveragePatient’s Insurance Company Name* Insurance ID #* This patient utilizes a Medicaid Managed Care Plan for diagnostic services. For diagnostic services, patient will not have any deductible, co-pays, or co-insurance due. If patient had deductible, co-pays, or co-insurance with the primary insurance, the patient will not be responsible for those. We will bill those charges to the Medicaid Managed Care Plan as secondary, up to the allowed amount per code with that plan.Is prior authorization required for diagnostic services with this Medicaid Managed Care Plan?* Yes No 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 benefits.PhoneThis field is for validation purposes and should be left unchanged. Δ
