Mental Health Counseling Minnesota Medicaid "*" indicates required fields Today's Date* MM slash DD slash YYYY Patient Name* First Last HiddenPhone*HiddenEmail* Clinic*Choose a ClinicGrounded LivingUplift Counseling CenterName of Insurance Company* Medicaid Insurance Coverage Patient has active coverage with this Medicaid plan, and Medicaid is the only insurance on file. For the mental health counseling services listed below, patient will not have any deductible, co-pays, or co-insurance due. Prior authorization is not required for these services. 90899 U8 Clinical Care Consultation Face to Face 5 to 10 min 90899 U8 U4 Clinical Care Consultation Non Face to Face 5 to 10 min 90899 U9 Clinical Care Consultation Face to Face 11 to 20 min 90899 U9 U4 Clinical Care Consultation Non Face to Face 11 to 20 min 90899 UB Clinical Care Consultation Face to Face 21 to 30 min 90899 UB U4 Clinical Care Consultation Non Face to Face 21 to 30 min 90899 UC Clinical Care Consultation Face to Face 31 min plus 90899 UC U4 Clinical Care Consultation Face to Face 31 min plus H0031 UA Administrating and reporting standardized measures H0032 UA Treatment review and developmentAdditional 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.CommentsThis field is for validation purposes and should be left unchanged. Δ
