Mental Health Counseling Commercial, WI Medicaid Managed Care "*" indicates required fields Today's Date* MM slash DD slash YYYY Patient Name* First Last HiddenPhone*HiddenEmail* Clinic*Choose a ClinicGrounded LivingUplift Counseling CenterImportant Information Patient has a commercial insurance as primary, and a Medicaid plan as secondary. We will show the regular benefits with patient’s commercial insurance, but understand the following: If patient’s care goes to the commercial insurance’s deductible, Medicaid will cover the charge at the Medicaid allowed amount (for mental health counseling services). If patient has co-insurance or a co-pay due with commercial insurance, we will follow the co-pay amount for Medicaid instead. Primary Insurance CoverageName of Insurance Company Clinic isChooseIn NetworkOut of NetworkInsurance Coverage for these codes: 90791 - Psychiatric Diagnostic Evaluation 90832 - Individual Psychotherapy 16-37 minutes 90834 - Individual Psychotherapy 38-52 minutes 90837 - Individual Psychotherapy 53 minutes plus 90785 - Interactive Complexity 90846 - Family Therapy without patient 26 minutes plus 90847 - Family Therapy with patient 26 minutes plus 90853 - Group psychotherapy (interpersonal processing)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 mental health counseling services? 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 mental health counseling services? Yes No Additional CommentsWI Medicaid Managed Care Plan is SecondaryName of Insurance Company* Medicaid Managed Care Plan Insurance Coverage Patient has active coverage with this Medicaid plan, and this insurance is secondary. 90791 - Psychiatric Diagnostic Evaluation 90832 - Individual Psychotherapy 16-37 minutes 90834 - Individual Psychotherapy 38-52 minutes 90837 - Individual Psychotherapy 53 minutes plus 90785 - Interactive Complexity 90846 - Family Therapy without patient 26 minutes plus 90847 - Family Therapy with patient 26 minutes plusIs prior authorization required for mental health counseling services?* 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. Δ
