Verification Of Benefits
Active Coverage?
Active
Inactive
Patient Name
Facility
Please Select
Pacific Palms Recovery
Sunsets Recovery Center
Dynamics
New Origins
Socal Empowered
Patient DOB
-
Month
-
Day
Year
Date
Insurance CO
Patient Gender
Please Select
Male
Female
Ins. Phone # (BH)
Subscriber Name/DOB
Member ID #
Relationship to Client
Please Select
Child
Parent
Self
Spouse
Group #
Employer Name
BH Carve-Out
Policy Type
Employer
Individual
Carve-Out ID #
Address on Policy (Street)
Effective Date
-
Month
-
Day
Year
Date
Address on Policy (City, State, Zip code)
Plan Funding
Self Funded
Fully Insured
Indigo Rep
Please Select
Nick
Amanda
Carly
Catherine
Kelly
Jon
Plan type
Please Select
PPO
POS
EPO
HMO
ASO
Time/Date of VOB
/
Month
/
Day
Year
Date
Plan Description
Spoke to/Call Ref #
Benefit Period
Please Select
Calendar Year
Plan/Contract Year
Pre-Cert Phone #:
Renewal/Term Date
/
Month
/
Day
Year
Date
Levels of Care Covered:
DTX [sub-acute] - H0010
Group Psychotherapy - 90853
RTC - H0018 / H0019
Ind. Psychotherapy - 90834
PHP - H0035 / S0201
Family Therapy - 90846 / 90847
A/d Tx Per Diem - H2036
Case Mgmt [CD] - H0006
IOP [CD] - H0015
Psychotherapy for Crisis - 90839
IOP [MH] - S9480
Ind. Psychotherapy (60 min) - 90837
Pre-Certification/Authorization required for:
DTX
RTC
PHP
IOP
OP
Non-Routine OP (60 min +)
Policy Details:
Primary
Secondary
On-Exchange
Off-Exchange
COBRA Plan
Grace Period
COB on file: (last updated)?
Yes
No
COB on file last updated date
-
Month
-
Day
Year
Date
Other Insurance
Yes
No
Carrier
Aetna Reimbursements:
Fee-Schedule
Reasonable Charges
50% Non-Par
National Advantage Program (NAP)
Cigna Reimbursements:
MRC-1
MRC-2
Average Contracted Rate (ACR)
United Healthcare Reimbursements:
MNRP
Shared Savings Program
Blue (“send to your local”):
Blue Cross
Blue Shield
TPA's/Networks/Pricers & Cost Containment
Please Select
First Health/Coventry
Global Claims Service (GCS)
HealthComp
MultiPlan
National Care Network (NCN)
Preferred Medical Claim Solutions (PMCS)
Private Healthcare Systems (PHCS)
Three Rivers Provider Network (TRPN)
Viant
Zelis
Plan Level Coinsurance, Deductibles & Maximums
Co-Insurance (%)
After OOP (%)
Ind. Deductible ($):
Ind. Deductible ($ met):
Family Deductible ($):
Family Deductible ($ met):
Ind. Out-of-Pocket* ($):
Ind. Out-of-Pocket* ($ met):
Family Out-of-Pocket ($):
Family Out-of-Pocket ($ met):
Is ded. included in the OOPM
Yes
No
Co-Pays
Admit Fee
Dollar/Day Max
LOC
Please Select
Sub-Acute Detox
Residential Treatment
Partial Hospitalization
Intensive Outpatient
Outpatient Therapy
Visit Limits
LOC
Please Select
Sub-Acute Detox
Residential Treatment
Partial Hospitalization
Intensive Outpatient
Outpatient Therapy
Rem:
Claims Mailing
Payer ID
Accreditations
Please Select
State License is Sufficient
JCAHO & State License Required
JCAHO or CARF
JCAHO - All Levels
JCAHO - Inpatient Only
CARF - All Levels
CARF - Inpatient Only
Reimbursement Details:
AOB Accepted?
Yes
No
Usual & Customary (UCR)
Yes
No
OON Allowed Amount
Yes
No
Priced By Local Plan
Yes
No
Priced By Home Plan
Yes
No
Medicare Rates (CMS)
Yes
No
Medicare Rates (%)
PHARMACY BENEFIT DETAILS:
Rx Benefit Admin
Rx Phone Number
Rx Bin
PCN
Rx Group
ADDITIONAL NOTES
UA - 81005/80305/G0480
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