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
Patient Data
Dependent Data
| Subscriber Data
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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. |
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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 | ||||||||||||
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Behavioral Health
| Medical
| Pharmacy
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Claim Details
Behavioral Claims
Payer ID A unique number that identifies the Behavioral Health insurance provider responsible for processing claims. | BH12345 |
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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 |
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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 |
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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 |
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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 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 |
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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 |
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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 |
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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 |
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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 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 |
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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 |
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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 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 |
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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 |
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