Counseling Services | Alpharetta GA | Holistic Wellness Practice
Integrative Health & Wellness Services

OON Insurance Verification

Use this form when contacting your insurance about out-of-network benefits.

OUT-OF-NETWORK INSURANCE VERIFICATION

 

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.

 

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 _____%

 

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 _____%

 

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?”