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<Name of Practice> INSURANCE QUESTIONNAIRETIN _________________ NPI Grp_________________ Address: _________________________________________Date:__________Time:__________ Checked by:_______ Person Spoke with:___________________ Ref:# ________________________________Section 1: Patient Data:Patient Name: __________________________________________________________Patient’s DOB: ___________________________________Patient’s Policy #___________________________________________________ Patient’s Group # _______________________________________ Section 2: Primary Insurance DataInsurance Co. Name:________________________________________________________ Payor ID # (For electronic billing):_________________Insurance Co. Phone #________________________________________ Claims Mailing Address:______________________________________ City, State, Zip: ________________________________________________ ____In-Network _ Out of NetworkSection 3: Insurance Plan/Eligibility Data ____ NO OUT OF NETWORK BENEFITSEffective Date:_________________ Calendar year plan? Y N Contract Plan: Y N Fiscal Year plan? Y N Dates ______________________ Co-pay:$___________ Is Co-Pay: ______ Per Visit _______ Per Procedure ________ Per ProviderDeductible: Ind $_____________ Family $_____________ Deductible Met Ind $__________ Family $_________ Co-insurance:% _________ Out of Pocket Max: Ind $______________ Family $_____________ Out of Pocket Max Met Ind $_____________ Family $_______________ Section 4: Chiropractic Manipulative Therapy, Physical Medicine/Modalities, Other Services- ARE THESE SERVICES COVERED??CMT Therapy (98940,41, 42, 43)______________________________ DME/SUPPLY E0730 ___Y ___N Auth Req?________________ Exam (99201-05/99211-5) ___________________________________DME/SUPPLY E0745 ___Y ___N Auth Req?________________ X-rays (ex. 72100):_________________________________________ DME/SUPPLY L0457 ___Y ___N Auth Req?________________ Trigger Point Injections (20552) ______________________________ DME/SUPPLY L0180 ___Y ___N Auth Req?________________ Joint Injections (20610) _____________________________________ DME/SUPPLY L1844 ___Y ___N Auth Req?________________ Passive Modalities (97012, 97014/G0283)_______________________DME/SUPPLY L0650 ___Y ___N Auth Req?________________ Physical Medicine (97110/97140) _____________________________DME/SUPPLY L3020 ___Y ___N Auth Req?________________Therapeutic Massage (97124) ________________________________DME COVERAGE SUMMARY ____________________________Section 5: Telemedicine Do you cover telemedicine services when rendered by a chiropractor? _____ Y _____ N Are these codes covered under telemedicine ___99202 ___99212 ___G2010 ___99421 ___99453 Are you following the COVID 19 CMS 1135 Waiver rules for expansion of telehealth services to include all CPT codes that can be rendered by telemedicine, or only codes that are approved for telemedicine in the CPT Code Book __________________________________________________Are approved telemedicine services covered the same as in person services ___ Y ___ N If NO, what are the coverage and benefits for telemedicine approved services? _____________________________________________________________________________________________Do you have OUT OF NETWORK benefits for Telemedicine? ___ Y ____ N Section 6: Limitations and Authorizations -Are there any limits on the covered services? Chiropractic Manipulations: Visit limit __________ Visits used to date _________ Yearly $ Limit _________ Yearly limit used $____________ Daily $ Cap $____________ Physical Medicine PT: Visit limit __________ Visits used to date _________ Cap on Modalities/Day? Y N If Y, daily cap __________Pre-Auth/Referral Required? Y N If Y, provide details of preauthorization requirements: __________________________________________________________________________________________________________________________________________________________________Do you accept assignment on out of network claims? (Will you pay the provider directly for any covered services?) ____ Y ____ N ................
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