VERIFICATION OF INSURANCE COVERAGE FOR ACUPUNCTURE - PRINT & COMPLETE
Name: _________________________________ Date: ________________
Here is what you do to verify coverage for Acupuncture care. Fill out this form completely (one for each insurance company you
have coverage with) and return to our office on your next visit.
DATE you phoned your insurance company: ______________________
NAME of the Insurance Company: ______________________
TELEPHONE NUMBER of Insurance Company: ______________________
NAME of company representative you speak with: ______________________
1. CALL your Insurance Company and ask the following questions:
a.
Does my policy cover Acupuncture? Yes____ No____If no, how can I get it included on my policy? ______________________________________
If yes, are there any limits to my coverage? Yes____ No____
What are those limits (Be as specific as possible)._______________________________________________
__________________________________________________________________________
Is there a limit to number of visits allowable? Yes____ No____ If yes, how many _______
Is there a maximum payment per treatment? Yes____ No____ What?________________
Will it cover a pre-existing condition? Yes____ No____ If yes, under what conditions ____
__________________________________________________________________________
Will it cover Laser Acupuncture? _______ TENS?_______ Herbs? _______
How does your company code these (it varies from company to company)? _____________
__________________________________________________________________________
What procedure code(s) does your company accept for Acupuncture? ____________________
Is coding by RVS or CPT standards? ____________________________________________
Do I need an M.D.'s or D.C.'s prescription for Acupuncture? Yes____ No____ Other ____
Explain: __________________________________________________________________
b.
What is the DEDUCTIBLE? ________ Is that yearly? Yes____ No____Per condition? ____ Per family member? ____ Per total family ____.
Has the deductible been paid? Yes____ No____ If yes, how much? _________
c.
What PERCENTAGE of the charges will my policy cover? _______%.It is initially _______% until $ _______ is reached and then _______% up to $ ____________
What percentage is covered on accidents? _______%
d.
What is the EFFECTIVE DATE of my policy? ________________________e.
Can benefits be assigned to my Acupuncturist's office? Yes____ No____f.
What is my CLAIM NUMBER? _____________________________________g.
Do you require reports for payment of Acupuncture? Yes____ No____If yes, how often?____________
What kind of report, if applicable: Short Form___ Initial ___ Interim Re-evaluation ___ Final ___
Other__________________________________________________________________
Does your company pre-authorize payment for report? Yes____ No____
h..
What is the ADDRESS of the office where claims are to be sent? ______________________________________________________________________________________________________
Verification of Insurance Coverage
For Acupuncture
Page 2
i.
To WHOSE ATTENTION is the claim sent?___________________________________________j.
PHONE NUMBER of Insurance Company Claims Department ____________________________Do you accept electronic billing? Yes____ No____ If yes, what phone number and other information does the
office need to do this? __________________________________________
_____________________________________________________________________________
k.
POLICY #: ___________________________ GROUP # _______________________INSURED's S.S.# __________________
NAME policy is under _____________________________________________
Employer's Name & Address _____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
2. Obtain an Insurance form from your agent or place of employment. Fill-in the required personal information COMPLETELY.
Write n/a for all questions not applicable. Attach our insurance billing form to a COPY of the insurance claim form.
3. THIS FORM MUST BE BROUGHT INTO OUR OFFICE COMPLETELY FILLED IN BEFORE WE CAN INITIATE A THIRD PARTY PAY SYSTEM. UNTIL THEN, FULL PAYMENT IS DUE ON THE DATE OF SERVICE.
4. PLEASE NOTIFY us when your insurance company changes.
If you have any questions please phone our office for assistance. We are happy to answer any questions you may have.
I state that the above answers are true and correct.
Signature _________________________________
Date: ________________________