Mental Health Counseling Wisconsin Medicaid Managed Care Plan "*" 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 Managed Care Plan Insurance Coverage Patient has active coverage with this Medicaid plan, and this insurance is the only insurance on file. 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)Is 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.EmailThis field is for validation purposes and should be left unchanged. Δ
