CONCIERGE SLEEP MEDICINE
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Insurance Verification Form
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Indicates required field
Patient Name
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First
Last
Patient ID
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Selec One
Passport
Driver Licence
Number
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Insurance
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Please Select One
Self Pay
Accendo Insurance Company
Aetna
American Family Life Assurance Co. Of Columbus
Amerigroup
Av-Med
Blue Cross and Blue Shield
Capital Health
Careplus Health
Celtic
CIGNA
Coventry
Coventry Health Plan Of Florida Inc.
Coventry Summit Health
Florida Health
Florida Health Care Plan
Freedom Health
Freedom Life
Golden Rule
Health First
Health First Health
Healthease Of Florida
Healthspring Of Florida
Health Options
Healthsun
Humana
Humana Health Ins. Co. Of Florida Inc
Magallan
Molina
Medica Healthcare
Metropolitan Life Insurance
Molina Healthcare Of Florida Inc.
Neighborhood Health Partnership
Oxford
Physicians United Plan Inc.
Preferred Care Partners
Prestige
Staywell
Sunshine
The Public Health Trust Of Dade County
Tricare (south region)
UMR
United Healthcare
Universal Health Care Plus
United Healthcare of Florida (MMA)
United Health System
Wellcare Of Florida
D O B
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Month/Date/Year
PCP
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Ins. Ph. Num.
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Gender
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Male
Female
PCP Number
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Policy Type
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Select One
HMO
PPO
POS
EPO
MMA
None
Social Security
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1st Study?
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Select One
Yes
No
Policy ID
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Phone Number
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Date Last Time
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Policy Group
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Sleep Study Requested
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Please Select One
95800 Sleep Study; Unattended
95805 Multiple Sleep Latency Test
95810 Polysomnography attended 4 or more Baseline (first night with 26 channels)
95811 Polysomnography attended 4 or more Split Night (all in one night, 26 channels & CPAP)
95811 Polysomnography with CPAP Titration (second night if positive in apnea, 26 channels and CPAP Tiration)
G0398 Home Sleep Study Test (HST) with Type II portable monitor, unattended, minimum of 7 channels
G0399 Home Sleep Study Test (HST) with Type III portable monitor, unattended, minimum of 4 channels
G0400 Home Sleep Study Test (HST) with Type IV portable monitor, unattended, minimum of 3 channels •E.g. Watch-PAT devices (Itamar Medical)
Policy Start Date
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Policy End Date
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In-Network Benefits
Co_Pay $
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Deductible $
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Is It Met?
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Please Select One
Yes
No
Met
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Remaining
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Co-Ins
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OOP $
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OOP Met $
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OOP Remaining $
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Requires Pre-Authorization?
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Please Select One
Yes
No
Notes:
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Notes:
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Reference Number
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Agent Name:
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Out-Network Benefits
Co-Pay $
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Deductible $
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Is It Met?
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Please Select One
Yes
No
Met
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Remaining
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Co-Ins
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OOP $
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OOP Met $
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OOP Remaining $
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Requires Pre-Authorization?
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Please Select One
Yes
No
Pre-Authorization Number
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Pre-Authorization Agent:
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Pre-Authorization Valid From-To:
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Verified By:
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Procedure Codes:
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Please Select One
95810
95811
Primary Dx Codes:
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Please Select One
327.23 OSA - Witnessd Breathing Pauses During Sleep
327.51 - Periodic Limb Movements During Sleep
333.94 - Restless Legs While Falling Asleep
347.00,01 - Narcolepsy - Daytime Sleep Attacks
780.51 - Insomnia With Apnea
780.52 - Insomnia Of Unknown Etiology
780.54 - Excessive Daytime Sleepiness/Hypersomnia
Other -
Supporting Dx (With a Primary Dx)
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Please Select One
278.00 - Obesity
278.01 - Morbid Obesity
780.09 - Somnolence or Droesiness
780.79 - Fatigue or Malaise
786.09 - Loud or Disruptive Snoring
307.45 - Shift Work Disorder
AISP Insurance References
Gonzalez and Castellanos (TAX ID: 65-0430812 NPI: 1447285606) ; DR Gonzalez (NPI: 1134152051) : DR Castellanos (NPI: 1326077967) : AISP (TAX ID: 52-2413969 NPI: 1093740235)
Next to the insurance’s name please find who they bill under. Split studies, authorization approved for both CPT codes 95810 and 95811is Required. Brenda (305) 824-3244
Medica (AISP)................................................. Commercial, Individual and Medicare Plans
Medicare (AISP)................................................................................................ No Medicaid
Molina Health Plans (AISP)
Preferred Care Partners (AISP)............................................................................... All Plans
Simply Health Plans (AISP)………………………….……..….……………….…..……All Plans
Tricare (AISP)……………………………………………….……………… ……………All Plans
United Health Care (G&C).HMO & PPO (No UHC Medicare Complete or Secure Horizons)
WellCare (AISP)....................................................................................................... All Plans
Other PPO’s.................................................................. Check with AISP prior to scheduling
Aetna (G&C) ................................................................................ EPO, PPO, POS & HMO
AvMed (AISP)............................................................................... PPO, EPO, POS & HMO
BCBS (G&C)....................... PPO, POS & Blue Options (NO HEALTH OPTIONS or HMO)
CarePlus (AISP).................................................................................................... All Plans
Cigna (G&C)..................................................................................... PPO, POS (NO HMO)
HealthSun (AISP)................................................................................................... All Plans
Humana (AISP)............................................... PPO, POS, EPO, HMO (with Authorization)
Leon Medical Centers Health Plan (AISP)............................................................. All Plans
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