Insurance Benefit Verification

Call Prep Sheet — Billing-Therapy.com

Telehealth Covered?

Yes No

Prior Auth Required?

Yes No

Copay Applies?

Yes No

Session / Billing Limit?

Yes No

1 Call Information

Date of Call

Call Time

Rep Name

Reference / Call ID

Insurance Company Phone *

Member Services Line

Hold Time (min)

2 Client / Member Information

Client Name *

Date of Birth

Member ID

Group Number

Relationship to Insured

Insurance Plan Name

3 Provider Information

Provider Name / Practice

Individual Provider NPI

Practice / Group NPI

Tax ID (EIN)

Provider State

Taxonomy Code

In-Network?

Yes No Unknown

4 Plan Details & Eligibility

Plan Type

Effective Date

Termination Date

Plan Year Resets

Benefits Active?

Yes No

Referral Required?

Yes No

Auth / Precertification Required?

Yes No Retroactive OK

Auth Number (if obtained)

5 Deductible & Out-of-Pocket

In-Network

Individual Deductible

Met So Far

Individual OOP Max

OOP Met So Far

Family Deductible

Met So Far

Family OOP Max

OOP Met So Far

Out-of-Network

Individual Deductible

Met So Far

Individual OOP Max

OOP Met So Far

6 Mental Health / Behavioral Health Benefits

MH Parity Confirmed?

Yes No

Managed by Separate Carve-out?

Yes No

Carve-out Entity Name

Outpatient Sessions / Year

Sessions Used YTD

Sessions Remaining

Copay (In-Network)

Coinsurance (In-Network)

Coinsurance (OON)

CPT Codes Verified — check all that apply

✗90837 (60-min)

✗90834 (45-min)

✗90832 (30-min)

✗90791 (Psych Eval)

✗90847 (Family)

✗90853 (Group)

✗99213 (E&M)

✗99214 (E&M)

Allowed Amount — 90837

Allowed Amount — 90834

Allowed Amount — 90791

7 Telehealth

Telehealth Covered?

Yes No

Same Benefit as In-Person?

Yes No

Platform Restriction?

Modifier Required

Place of Service Code

Telehealth Billing Limit (if any)

8 Claims Submission

Claims Mailing Address

Electronic Payer ID

Claims Phone

Timely Filing Limit

COB — Secondary Insurance?

Yes No

Secondary Insurance Name

9 Known Issues / Denial History

Prior Claim Status

Denial Code(s) if Known

Notes on denial / issue context

★ Prompt Pay / Delayed Claim Interest Calculator

Provider State

Claim Amount ($)

Date Claim Submitted

Claim Type

Electronic Paper

10 General Call Notes

Notes

Follow-up Action Required?

Yes No

Follow-up Date

Follow-up Action

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