Member Information

Full Name *

Phone *

Initial Coverage Questions

Do I have out-of-network chiropractic benefits?

Yes

No

If NO, end the call. Record.

Representative's Name

Call Reference Number

Deductible Information (Only if YES to Q1)

What is my individual out-of-network deductible?

How much of that deductible has already been met?

If deductible is more than $1,500, end the call. Record:

Representative's Name:

Call Reference Number:

Claims Routing

Are my chiropractic claims processed through ASH (American Specialty Health)?

Yes

No

If YES, end the call. Record:

Representative Name:

Claim Call Reference Number:

Coverage Details

The percentage of chiropractic services are covered?

How many chiropractic visits allowed per year?

This is a Multi-Plan account?

Yes

No

Plan is based on a Calendar Year or Month-to-Month?

Calendar Year

Month-to-Month

Procedure Code Coverage

Please confirm coverage for the following procedure codes:

G0283: Electric stimulation

Covered

Not Covered

S8948: Laser therapy application

Covered

Not Covered

97124: Massage therapy

Covered

Not Covered

Acknowledgement

Patient Signature:

Clear

Today's Date

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