CONCIERGE SLEEP MEDICINE
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    Insurance Verification Form

    Month/Date/Year
    In-Network Benefits
    Out-Network Benefits
    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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