Please call the 800 number on your insurance card and complete this form with a customer service representative via telephone. It is important that you understand your insurance coverage prior to starting services at HWP.
Client Name
Insured Name:
Insurance Company:
- Insurance Phone Number:
- Mental Health Insurance (may be different than health insurance):
- Claims Address:
- Client Insurance ID#:
- Group #:
Mental Health 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 Therapy, 60 minutes (CPT Code 90837): □ YES □ NO _____%
- Family Therapy, without patient present (CPT CODE 90846): □ YES □ NO _____%
- Couples, Marriage, & Family Therapy, with patient present (CPT CODE 90847): □ YES □ NO _____%
- Group Therapy (CPT Code 90853): □ YES □ NO _____%
- Psychiatric Diagnostic Evaluation (CPT Code 90792): □ YES □ NO _____%
- Level 3 Visit – Psych. Followup (CPT Code 99213): □ YES □ NO _____%
- Level 4 Visit – Psych. Followup (CPT Code 99214): □ YES □ NO _____%
Video Sessions:
- Individual Therapy, 30 minutes (CPT Code 90832-95): □ YES □ NO _____%
- Individual Therapy, 45 minutes (CPT Code 90834-95): □ YES □ NO _____%
- Individual Therapy, 60 minutes (CPT Code 90837-95): □ YES □ NO _____%
- Family Therapy, without patient present (CPT CODE 90846-95): □ YES □ NO _____%
- Couples, Marriage, & Family Therapy, with patient present (CPT CODE 90847-95): □ YES □ NO _____%
- Group Therapy (CPT Code 90853-95): □ YES □ NO _____%
- Psychiatric Diagnostic Evaluation (CPT Code 90792-95): □ YES □ NO _____%
- Level 3 Visit – Psych. Followup (CPT Code 99213-95): □ YES □ NO _____%
- Level 4 Visit – Psych. Followup (CPT Code 99214-95): □ YES □ NO _____%
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?”
Note: HWP is not responsible for coverage or reimbursement. Please be advised that time spent performing insurance-related requests exceeding 15 minutes is not included in the session rate and will be billed at your provider’s hourly rate. Coaching sessions, wellness services, workshops and recommended testing through third-party companies (e.g. neuroendocrine and pharmacogenetic testing) are not eligible for insurance reimbursement.
