Behavioral Neuropsychology, LLC
BDTX - "Calling Your Insurer" Worksheet
Instructions for calling your insurance carrier to determine YOUR PLAN BENEFITS for psychological assessments or treatments.
If you know who is doing evaluation or therapy, please check box.
Antonia Forster, PhD, ABPP
Michael Fulop, PsyD
Justin Lee, PhD
Kiryl Shada, PsyD
Unknown
Patient's Name
*
First Name
Last Name
Patient 1st & Last Initials
Patient's Date of Birth [mm/dd/yyyy]
Person Completing this Form [Your Name]
*
First Name
Last Name
Your email address
example@example.com
Before you call: find your insurance card
Record the answers in the spaces provided
SUBSCRIBER'S NAME ["Same" if Subscriber is Person Completing Form]
First Name
Last Name
SUBSCRIBER'S EMPLOYER
SUBSCRIBER'S Insurance Carrier [or Company on front of card]
SUBSCRIBER'S Insurance ID#
SUBSCRIBER'S Group ID#
Insurance Carrier's Phone #
Then, call your insurer, ask these questions
Record the answers in the spaces provided
Date & Time You Called
*
Name of 1st Person you talked with, their direct line phone # if possible
Ask for their first and last name
Name of person you were transferred and spoke with, their direct line phone # if possible?
Ask for their first and last name
What is the coverage for PSYCHOTHERAPY by a LICENSED PSYCHOLOGIST who is out of network?
[CPT Codes 90834 or 90837]
Is PRE-AUTHORIZATION needed?
[CPT Codes 90834 or 90837]
If YES, how is PRE-AUTHORIZATION obtained?
[CPT Codes 90834 or 90837]
What is the Rate of Reimbursement?
[CPT Codes 90834 or 90837]
What is the number of sessions covered without pre-authorization?
Add comments or notes for this section:
For this section
What is the coverage for Neuropsychological [or psychological] Testing/Scoring by a LICENSED PSYCHOLOGIST who is out of network?
[CPT Codes 96136 or 96137]
Is PRE-AUTHORIZATION needed?
[CPT Codes 96136 or 96137]
How is PRE-AUTHORIZATION obtained?
[CPT Codes 96136 or 96137]
What is the Rate of Reimbursement?
[CPT Codes 96136 or 96137]
Add comments or notes for this section:
For this section
What is the coverage for Psychological Testing/Scoring by a technician?
[CPT Codes 96138 or 96139]
Is PRE-AUTHORIZATION needed?
[CPT Codes 96138 or 961379]
If YES, how is PRE-AUTHORIZATION obtained?
[CPT Codes 96138 or 96139]
What is the Rate of Reimbursement?
[CPT Codes 96138 or 96139]
Add comments or notes for this section
For this section
What is the coverage for Neuropsychological/Psychological Test INTERPRETATION by LICENSED CLINICAL PSYCHOLOGISTS out of network?
[CPT Codes 96130 or 96131]
Is PRE-AUTHORIZATION needed?
[CPT Codes 96130 or 96131]
If YES, how is PRE-AUTHORIZATION obtained?
[CPT Codes 96130 or 96131]
What is the Rate of Reimbursement?
[CPT Codes 96130 or 96131]
Is there a dollar limit on your outpatient mental health coverage?
If so, what is the dollar limit?
If YES to the previous question, what diagnoses are excluded?
Do we have diagnoses excluded from our outpatient mental health coverage?
Amount of our deductible? Has our deductible been met?
Please verify you humanity
*
Submit
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