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QUOTE OF BENEFITS
FORM
This Quote of Benefits Form will help
us determine what your insurance benefits are and
consequently, what your out-of-pocket costs will be. Please
complete the information in Part One. Part Two is for you to
fill out as you speak to your insurance provider
representative.
Part
One
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Patient Name:
Patient Date of
Birth:
Insured's Name:
Insured's Date of
Birth:
Insured's Social Security
#:
Insured's Zip Code
Insured's
Employer:
Insurance Company
Name:
Insurance Company Phone
Number:
Policy ID #:
Policy Group #:
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Part Two
Telephone Script to Call Your
Insurance Company
Tell the insurance company
representative: "Hi, my name is _______ and I am calling to
obtain a quote of benefits for my insurance plan. My first
question is:
1. Is my insurance policy considered a
PPO plan? YES or NO.
- If NO, unfortunately HMOs do not
reimburse fees that are associated with my medical
services.
However, they may pay for laboratory testing. Ask: "Does
my insurance policy pay for laboratory testing that was
ordered at a participating laboratory company (e.g.,
Quest Diagnostics or LabCorp) by an out-of-network
physician?"
- If YES, and you have a PPO you
will be considered out of network. Proceed to Part Three
below.
Part Three - Out-of-Network
PPO Plans
Tell the representative: "I would like
a quote of benefits for an OUT-OF-NETWORK sick medical
office visit with a family practice doctor."
Today's date and time:
I spoke with:
What is my effective date of
coverage?
Do I have a deductible?
If yes, how much is my
deductible?
How much of my deductible has been met
so far?
When does my deductible renew?
Calendar or policy year?
What is my maximum out of
pocket?
Has anything been applied to my out of
pocket?
What is the percent of coverage for
in-office diagnostic lab work?
At what percentage are my claims
paid?
(Example: If you are covered at 80%, your insurance company
will pay 80% of what they consider a "usual and customary
fee" for the type of medical services that you will receive.
This will be based on the diagnosis codes (ICD-9) and
procedure codes (CPT) that are printed on my billing
statements.)
What is the mailing address for
sending claims?
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