Diagnostic No Insurance Coverage

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MM slash DD slash YYYY
Patient Name*
No Insurance Coverage
Upon checking with this insurance company, the patient does not have any coverage for Diagnostic care.

The patient has a Medicaid Managed Care Plan of which the clinic is not in network with. And this Medicaid Managed Care Plan is not open for any clinics to join their network. And the patient does not have any out of network care. So the patient’s diagnostic care will not be covered at the clinic.

If patient does get an autism diagnosis and needs ABA therapy, then patient’s ABA therapy will be covered under straight Forward Health Medicaid. This Medicaid Managed Care Plan will not be involved for billing for ABA therapy. The Medicaid Managed Care Plan only applies for Diagnostic treatment.
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.
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