Client Name
- DOB:
- SSN:
Insured Name:
- DOB:
- SSN:
Insurance Company:
- Insurance Phone Number:
- Mental Health Insurance (may be different than health insurance):
- Claims Address:
- Client Insurance ID#:
- Group #:
Counseling Services
1) “Do I have mental/behavioral health coverage?” □ YES □ NO
If YES, continue.
2) “Do I have Out-of-Network benefits?” □ YES □ NO
If YES, continue.
3) “Do I have an Out-of-Network deductible?” □ YES □ NO
If YES, “What is my out-of-network deductible?”
“How much of my out-of-network deductible has been met?”
4) “Please verify that the following services are covered under my policy? If YES, what percentage?”
In-Person Sessions:
- Individual Therapy, 30 minutes (CPT Code 90832): □ YES □ NO _____%
- Individual Therapy, 45 minutes (CPT Code 90834): □ YES □ NO _____%
- Individual/Couples/Family Therapy, 60 minutes (CPT Code 90837): □ YES □ NO _____%
- Family Therapy, without patient present (CPT CODE 90846): □ YES □ NO _____%
- Family Therapy, with patient present (CPT CODE 90847): □ YES □ NO _____%
- Group Therapy (CPT Code 90853): □ YES □ NO _____%
- *Psychological and psycho-educational testing codes vary. Please speak to your provider.
Video Sessions:
- Individual Therapy, 30 minutes (CPT Code 90832-95): □ YES □ NO _____%
- Individual Therapy, 45 minutes (CPT Code 90834-95): □ YES □ NO _____%
- Individual/Couples/Family Therapy, 60 minutes (CPT Code 90837-95): □ YES □ NO _____%
- Family Therapy, without patient present (CPT CODE 90846-95): □ YES □ NO _____%
- Family Therapy, with patient present (CPT CODE 90847-95): □ YES □ NO _____%
- *Psychological/Psycho-educational testing codes vary. Please speak to your provider.
5) “Do I need an authorization to receive any of these services?” □ YES □ NO
If YES, “What is my authorization number?”
“How many sessions are authorized?”
6) “What forms do I need to submit for reimbursement?”
7) “Do you require the providers signature on the superbill?”
8) “What is the most efficient way to submit these forms?”
