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Verification of Benefits Reference Guide

Welcome to the Interactive Verification of Benefits Example. This tool is designed to provide you with clear guidance and comprehensive information about your benefits. Whether you’re reviewing your coverage details, understanding your claim processes, or exploring various benefit types, this example will help answer any questions you may have.

Navigate through the sections below to explore patient and subscriber data, insurance plan specifics, claim details, and more. Interactive elements such as tooltips are available throughout the document to offer additional explanations and ensure you fully understand the information presented.

Our goal is to make the verification of benefits process as transparent and user-friendly as possible. If you need further assistance, please reach out to our team.

Verification of Benefits

Benefit information provided does not guarantee claim payment.

October 09, 2024 11:39 AM

Facility: Greenwood Medical Center

Patient Data

Patient Name
The complete legal name of the patient as recorded in official documents.
Emily Rose Thompson
Address
The permanent residential address where the patient resides.
456 Oak Avenue, Springfield, IL 62704
Date of Birth (DOB)
Date of Birth indicating the patient’s age.
August 22, 1992
Social Security Number (SS#)
A unique nine-digit Social Security Number assigned to the patient for identification.
123-45-6789
Gender
The biological sex of the patient as registered.
Female
Phone
The primary telephone number for contacting the patient.
(217) 555-1234
Alternate Phone
An alternative telephone number for reaching the patient if the primary number is unavailable.
(217) 555-5678

Dependent Data

Dependent Name
Full name of the dependent covered under the patient’s insurance plan.
Michael Thompson
Dependent Member ID
A unique identifier assigned to the dependent within the insurance plan.
DEP9876543210
Relationship
The familial relationship of the dependent to the primary subscriber.
Son
Date of Birth (DOB)
Date of Birth of the dependent, indicating age.
February 14, 2015
Address
Residential address of the dependent, typically same as the patient.
456 Oak Avenue, Springfield, IL 62704

Subscriber Data

Subscriber Name
Full name of the individual who holds the primary insurance policy.
Christopher Thompson
Subscriber Member ID
A unique identifier assigned to the subscriber within the insurance plan.
SUB1234567890
Date of Birth (DOB)
Date of Birth of the subscriber, indicating age.
November 05, 1985
Address
Residential address of the subscriber, typically same as the patient.
456 Oak Avenue, Springfield, IL 62704

Insurance Company Plan

Plan Details
Specific details about the insurance company’s plan, including coverage areas and limitations.
Benefit Types
Information regarding different types of benefits offered under the plan.
Insurance Provider
The official name of the insurance provider offering the coverage.
Employer
Name of the company or organization providing the insurance benefits to its employees.
BrightTech Innovations
BEH:
Information regarding Behavioral Health benefits, which cover mental health services.
MindCare Behavioral Health Services
MED:
Details about Medical benefits, including hospital stays, surgeries, and general medical care.
MedWell Insurance
Name of Insurance Company
The official name of the insurance provider offering the coverage.
MedWell Insurance
Group Number
A unique number identifying the specific insurance group or employer within the insurance company.
GRP987654
  Pharmacy Benefits Manager
The third-party administrator responsible for managing prescription drug benefits.
PharmaServe LLC
Behavioral Health Medical Pharmacy

Behavioral Health

Plan ID
Unique identification number assigned to the Behavioral Health plan for tracking and reference.
BH2024001
Contact Number
Contact number for reaching the Behavioral Health services provider or support center.
800-555-2468

Medical

Plan ID
Unique identification number assigned to the Medical plan for tracking and reference.
MED2024001
Contact Number
Contact number for reaching the Medical services provider or support center.
800-555-1357

Pharmacy

Plan ID
Unique identification number assigned to the Pharmacy benefits plan for tracking and reference.
PHM2024001
Contact Number
Contact number for reaching the Pharmacy services provider or support center.
800-555-8642
Benefit information provided does not guarantee claim payment. Page 1 of 5

Claim Details

Behavioral Claims

Payer ID
A unique number that identifies the Behavioral Health insurance provider responsible for processing claims.
BH12345
Address
The official mailing address where the Behavioral Health insurance provider receives correspondence and claims.
789 Health Street, Wellness City, WC 54321
Coverage Type
Different types of insurance coverage options available under the Behavioral Health plan.

Plan/Calendar Year
The specific year or period during which the insurance plan is active and provides coverage.
2024
Plan Begins
The start date when the insurance coverage becomes effective.
January 01, 2024
Paid Through Date
The date until which the insurance premiums have been paid, ensuring coverage up to that point.
December 31, 2024
Behavioral Claims Pay Rate
The percentage of covered Behavioral Health services that the insurance plan will pay after deductibles and copays.
80%

Medical Claims

Payer ID
A unique number that identifies the Medical insurance provider responsible for processing claims.
MC67890
Address
The official mailing address where the Medical insurance provider receives correspondence and claims.
456 Care Avenue, Healing Springs, HS 98765
Grace Period
The period after the premium due date during which coverage remains active without interruption.
30 days
Plan Ends
The end date when the insurance coverage ceases unless renewed or extended.
December 31, 2024
Payment Made To
The entity (e.g., healthcare provider or pharmacy) that receives payments from the insurance for covered services.
Healthcare Provider
License Requirements
The type of professional licenses required for providers to offer services under the insurance plan.
State License

Claim Details Continued

Does COB Need to be Updated?
Determines whether the Coordination of Benefits information needs to be revised or updated.
No
Are PHP, IOP, and OP Covered as Telehealth?
Indicates whether Partial Hospitalization Programs (PHP), Intensive Outpatient Programs (IOP), and Outpatient Programs (OP) are covered when provided via telehealth services.
Yes
Are There Any Pre-existing Clauses or Waiting Periods?
Checks if there are any restrictions or waiting periods before coverage begins for pre-existing conditions.
No
Is PHP Considered an Inpatient Level of Care (LOC)?
Determines if Partial Hospitalization Programs are classified as inpatient levels of care within the insurance plan.
No
Are Substance Abuse and Mental Health Benefits Combined?
Indicates whether benefits for substance abuse treatment and mental health services are integrated within the same plan.
Yes
4th Quarter Carryover for Deductible Accumulations?
Specifies whether deductible amounts from the fourth quarter are carried over to the next year’s deductible.
Yes
Does Deductible Apply to Out-of-Pocket Maximum (OOP)?
Indicates whether the deductible amount counts towards the Out-of-Pocket (OOP) maximum limit.
Yes
Are Freestanding Facilities Covered?
Determines if independent healthcare facilities (not affiliated with hospitals) are covered under the insurance plan.
Yes
Is Sub-Acute Detox Covered in a Freestanding Facility or a Residential Treatment Center?
Specifies whether Sub-Acute Detoxification services are covered when provided in independent facilities or residential treatment centers.
Both
Pre-existing Clause?
Indicates whether there are any clauses related to pre-existing conditions that affect coverage.
No
Does This Policy Cover Substance Abuse/Mental Health Treatment Outside of the Patient’s Home State?
Determines if the insurance plan provides coverage for substance abuse and mental health treatments received in states other than where the patient resides.
Yes
In/Out Network Cross Accumulation
Indicates whether in-network and out-of-network expenses are combined towards the deductible and out-of-pocket maximum.
Yes
Funding
Describes the type of funding arrangement for the insurance plan, such as fully insured or self-funded.
Fully Insured
Does Copay Apply to Out-of-Pocket Maximum (OOP)?
Specifies whether copayments count towards the Out-of-Pocket (OOP) maximum.
Yes
Benefit information provided does not guarantee claim payment. Page 2 of 5

Benefit Data (In Network)

Individual Accumulations

Partial Hospitalization Program (PHP)

Deductible
The amount you must pay out-of-pocket for covered services before your insurance begins to pay.
$1,250.00 Out-of-Pocket Maximum (OOP)
The most you will have to pay for covered services in a plan year. After reaching this limit, your insurance covers 100% of covered services.
$4,890.00
Deductible Met
The portion of your deductible you have already paid towards covered services.
$25.24 OOP Met
The amount you have already paid towards your out-of-pocket maximum.
$167.33
Deductible Remaining
The remaining amount you need to pay to meet your deductible.
$1,224.76 OOP Remaining
The remaining amount you can pay before reaching your out-of-pocket maximum.
$4,722.67
Patient Coinsurance Percentage
The percentage of costs for covered services you are responsible for after meeting your deductible.
20% Days Per Calendar Year (PCY)
The number of days services are covered within a single calendar year.
Unlimited
Lifetime Maximum
The maximum total amount your insurance plan will pay for covered services over your lifetime.
UNLIMITED Days Used
The number of days services have been utilized in the current period.
N/A
Copay
A fixed amount you pay for a covered service, typically at the time of service.
$0.00    

Intensive Outpatient Program (IOP)

Deductible
The amount you must pay out-of-pocket for covered services before your insurance begins to pay.
$1,250.00 Out-of-Pocket Maximum (OOP)
The most you will have to pay for covered services in a plan year. After reaching this limit, your insurance covers 100% of covered services.
$4,890.00
Deductible Met
The portion of your deductible you have already paid towards covered services.
$300.00 OOP Met
The amount you have already paid towards your out-of-pocket maximum.
$1,200.00
Deductible Remaining
The remaining amount you need to pay to meet your deductible.
$950.00 OOP Remaining
The remaining amount you can pay before reaching your out-of-pocket maximum.
$3,690.00
Patient Coinsurance Percentage
The percentage of costs for covered services you are responsible for after meeting your deductible.
20% Days Per Calendar Year (PCY)
The number of days services are covered within a single calendar year.
Unlimited
Lifetime Maximum
The maximum total amount your insurance plan will pay for covered services over your lifetime.
UNLIMITED Days Used
The number of days services have been utilized in the current period.
N/A
Copay
A fixed amount you pay for a covered service, typically at the time of service.
$25.00    

Outpatient Program (OP)

Deductible
The amount you must pay out-of-pocket for covered services before your insurance begins to pay.
$1,250.00 Out-of-Pocket Maximum (OOP)
The most you will have to pay for covered services in a plan year. After reaching this limit, your insurance covers 100% of covered services.
$4,890.00
Deductible Met
The portion of your deductible you have already paid towards covered services.
$500.00 OOP Met
The amount you have already paid towards your out-of-pocket maximum.
$2,390.00
Deductible Remaining
The remaining amount you need to pay to meet your deductible.
$750.00 OOP Remaining
The remaining amount you can pay before reaching your out-of-pocket maximum.
$2,390.00
Patient Coinsurance Percentage
The percentage of costs for covered services you are responsible for after meeting your deductible.
20% Days Per Calendar Year (PCY)
The number of days services are covered within a single calendar year.
Unlimited
Lifetime Maximum
The maximum total amount your insurance plan will pay for covered services over your lifetime.
UNLIMITED Days Used
The number of days services have been utilized in the current period.
N/A
Copay
A fixed amount you pay for a covered service, typically at the time of service.
$15.00    

Family Accumulations

Partial Hospitalization Program (PHP)

Deductible
The total amount your family must pay out-of-pocket for covered services before insurance begins to pay.
Family Total Out-of-Pocket Maximum (OOP)
The maximum amount your family will pay for covered services in a plan year. After reaching this limit, insurance covers 100% of covered services.
$9,780.00
Deductible Met
The portion of the deductible your family has already paid.
$500.00 OOP Met
The portion of the Out-of-Pocket maximum your family has already paid.
$1,800.00
Deductible Remaining
The remaining amount your family needs to pay to meet the deductible.
$750.00 OOP Remaining
The remaining amount your family can pay before reaching the Out-of-Pocket maximum.
$7,980.00
Patient Coinsurance Percentage
The percentage of costs for covered services your family is responsible for after meeting the deductible.
20% Days Per Calendar Year (PCY)
The number of days services are covered within a single calendar year.
Unlimited
Lifetime Maximum
The maximum total amount your insurance plan will pay for covered services over your lifetime.
UNLIMITED Days Used
The number of days services have been utilized in the current period.
N/A
Copay
A fixed amount your family pays for a covered service, typically at the time of service.
$0.00    
Benefit information provided does not guarantee claim payment. Page 3 of 5

Benefit Data Continued

Intensive Outpatient Program (IOP)

Deductible
The amount the family must pay out-of-pocket before the insurance starts covering services.
Family Total Out-of-Pocket Maximum (OOP)
The maximum amount the family will pay for covered services in a plan year. After reaching this limit, the insurance covers 100% of covered services.
$9,780.00
Deductible Met
The portion of the deductible that the family has already paid.
$500.00 OOP Met
The portion of the Out-of-Pocket maximum that the family has already paid.
$1,800.00
Deductible Remaining
The remaining amount the family needs to pay to meet the deductible.
$750.00 OOP Remaining
The remaining amount the family can pay before reaching the Out-of-Pocket maximum.
$7,980.00
Patient Coinsurance Percentage
The percentage of covered services the family is responsible for after meeting the deductible.
20% Days Per Calendar Year (PCY)
The number of days services are covered within a calendar year.
Unlimited
Lifetime Maximum
The maximum total amount the insurance plan will pay for covered services over the lifetime of the policy.
UNLIMITED Days Used
The number of days services have been utilized in the current period.
N/A
Copay
A fixed amount the family pays for a covered service, typically at the time of service.
$0.00    

Outpatient Program (OP)

Deductible
The amount the family must pay out-of-pocket before the insurance starts covering services.
Family Total Out-of-Pocket Maximum (OOP)
The maximum amount the family will pay for covered services in a plan year. After reaching this limit, the insurance covers 100% of covered services.
$9,780.00
Deductible Met
The portion of the deductible that the family has already paid.
$500.00 OOP Met
The portion of the Out-of-Pocket maximum that the family has already paid.
$1,800.00
Deductible Remaining
The remaining amount the family needs to pay to meet the deductible.
$750.00 OOP Remaining
The remaining amount the family can pay before reaching the Out-of-Pocket maximum.
$7,980.00
Patient Coinsurance Percentage
The percentage of covered services the family is responsible for after meeting the deductible.
20% Days Per Calendar Year (PCY)
The number of days services are covered within a calendar year.
Unlimited
Lifetime Maximum
The maximum total amount the insurance plan will pay for covered services over the lifetime of the policy.
UNLIMITED Days Used
The number of days services have been utilized in the current period.
N/A
Copay
A fixed amount the family pays for a covered service, typically at the time of service.
$15.00    
Benefit information provided does not guarantee claim payment. Page 4 of 5

Benefit Data Continued

Pre-Certification Required For:







Pre-Certification Company
The insurance company or third-party administrator responsible for handling pre-certification requests and approvals.
UM Insurance
Contact Number
The telephone number to call for submitting pre-certification requests or inquiries regarding the pre-certification process.
800-762-7897
Penalty Terms
Specific terms outlining the penalties or consequences for failing to obtain pre-certification when required.
Claim Denied
Pre-Cert Time Requirement
The timeframe within which pre-certification must be obtained after a request is received to ensure coverage.
15 Calendar Days After Request Received

Benefit Notes

SHP – Plan B – All (Non-MP)Specific Health Plan details pertaining to Plan B for all members except those in the Medicare Part (MP) program.: PPOPreferred Provider Organization, a type of health insurance plan that offers a network of healthcare providers.

INN Telehealth coverage for IOPIn-network telehealth services coverage for Intensive Outpatient Programs.? WILL APPLY DED & COINSURANCEThe deductible and coinsurance will be applied to the services rendered.

What platform? PROVIDER’S PLATFORMThe specific telehealth platform used by the healthcare provider for delivering services.

Is there any provider restrictions? CREDENTIAL WILL BE COVEREDProvider credentials will be verified and covered under the insurance plan.

Representative Name
The name of the insurance company representative who handled the verification of benefits.
Beatrice Anderson Verified By
The name of the individual who officially verified the benefits information.
Michael Tallia Reference Number
A unique number assigned to this verification for tracking and reference purposes.
52121942
Benefit information provided does not guarantee claim payment. Page 5 of 5