Info Needed Report-ABA

Your Name*
First Last
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Email*
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Phone*
Choose Clinic*
Date of Report*
MM slash DD slash YYYY
Demographics Needed
Please complete the ABA Insurance Verification Request Form for this patient so that we can get patient’s demographics, diagnosis, and/or insurance card needed for billing.
Prescription Form Needed
Please upload the patient’s prescription form in Teamwork Chat.
Modifier Needed
Please let us know in Teamwork Chat which modifier that this patient with Medicaid will utilize. TG or TF
Billing Form Clarification
On the following billing form submitted, we need additional clarification. Please let us know in Teamwork Chat the answer to our question(s).
Medicaid Prior Authorizations Expiring Soon
The following Medicaid Prior Authorizations are set to expire soon. Here is the patient name and date that the current prior auth will expire with Medicaid.
Other
Phone
This field is for validation purposes and should be left unchanged.