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You may find the following form useful when talking to your insurance provider.
You can fill out this page while you are online, printing it out when you are finished speaking to your insurance provider. Or, you may
download the form here (PDF), print it and fill it out while talking to your insurance provider. (left click to download the form, choose "save", save it to someplace that you can find it… desktop perhaps). In either case, please bring the completed form with you to your first visit.
Fill this top portion in BEFORE you call your insurance company:
Patient Name:
Date of Birth:
Look on the back of your card for a phone number for mental health. It maybe abbreviated as MH or MH/SA, as in mental health/substance abuse. If there is no number for mental health, call the member services number. This number is usually on the back of the card as well.
Insurance Company:
Insurance Company Phone Number:
Patient's ID Number:
Group Number:
Fill in the following during your call.
Keep a copy of this form and give a copy to your provider.
Call your insurance company. Follow the prompts to speak with a representative about your benefits. If there is a specific prompt for mental health, go there.
Date of Call:
Time of Call:
Spoke With:
When a representative picks up, say the following (make sure to say the words in italics): "I would like to find out what my outpatient mental health benefits are." The representative will ask you for your indentification information. Once they have indentified you, ask the following questions:
1. "Does my plan cover outpatient mental health services?"
Yes____ No____
If they don't, then you are done with the call. Speak to Dr. Ray about a cash payment arrangement if you still want to see him.
2. "Is Dr. Ray Wm. Smith a contracted provider with
Yes____ No____
a. If yes, proceed to the next questions.
b. If no, ask "Does my plan have out-of-network out patient mental health benefits?"
If not, then your call is complete. Speak with Dr. Ray about a cash payment arrangement.
3. "Do I have a deductible on my plan?"
Yes____ No____
a. If yes, ask "How much is it?" $_____________
4. "Has it been met for the year?"
Yes____ No____
a. If no, ask "How much is remaining?" $_____________
5. "What date does my coverage renew on?" ___/___/___
If the representative says "calendar year," that means that your coverage starts over on January 1st.
6. "How many visits do I get per year?" ________
7. "How many visits have been used?" ________
8. "Do I have a co-pay or co-insurance?"
Yes____ No____
a. If yes, ask "how much is it?"
Co-pay $________ Co-insurance $________
A co-pay is an exact dollar amount for which you are responsible for each visit.
A co-insurance is a percentage for which you are responsible for each visit.
(It is possible to have both.)
9. "Does my plan cover family therapy?" Yes___ No____
If asked for a procedure code, tell them "90847"
10. If applicable, ask "Does my plan cover marriage counseling?" Yes____ No____
11. If applicable, ask "Does my plan cover group therapy?"
Yes____ No____
If asked for a procedure code, tell them "90853"
12. "Does my plan require a referral from my Primary Care Provider?" Yes____ No____
a. If yes, contact your Primary Care Provider and ask them to give you a referral to see Dr. Ray Wm. Smith
13. "Does my plan require an authorization?" Yes____ No____
a. If yes, ask "What do I need to do to get an authorization?"
Then follow the representative's instructions.
b. Once an authorization is obtained, get the following information from the representative:
Authorization Number ___________________
Date Range of Authorization : Start Date ___/___/___ End Date ___/___/___
Number of Visits Authorized _________
No further information is needed. You may end the call unless you have further questions about your insurance.
Be sure to bring a copy of this form to your first appointment.
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Outpatient Mental Health Benefits Summary
