Form06 - [FORM 6Use the top of this page for your...

Info iconThis preview shows pages 1–2. Sign up to view the full content.

View Full Document Right Arrow Icon
[ FORM 6 —Use the top of this page for your letterhead.] Questionnaire for Determining Behavioral Health Insurance Benefits Try to get an answer to each question, and make longer notes if you need to, so you can be clear about the coverage. You will need to have this information before you call: Patient’s name: Patient’s date of birth: Patient’s ID/SS #: Policy holder’s name (if different from patient): Policy holder’s date of birth: Policy holder’s ID/SS #: Policy holder’s employer: Address of policy holder’s employer: Name of MCO or other insurer: Policy #: Group #: Renewal date: Name of any behavioral health subcontractor: Phone # Buttons or prompts Date(s) called Name(s) of representative(s) spoken with 1. Is this specific patient covered under this policy? q Yes q No 2. Are services for treating “mental and nervous disorders” covered? q Yes q No Are services for treating “drug and alcohol disorders” covered? q Yes q No 3. Is “outpatient psychotherapy”or “outpatient mental health/behavioral health treatment” q Yes q No for these disorders covered? 4. Will the insurance pay for these kinds of treatment?
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Image of page 2
This is the end of the preview. Sign up to access the rest of the document.

Page1 / 3

Form06 - [FORM 6Use the top of this page for your...

This preview shows document pages 1 - 2. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online