New Patient Insurance Benefits Verification Checklist
Builds a complete checklist of what to ask an insurance company before a new patient's first visit, then turns the notes from the call into a clean benefits summary the front desk and the patient can understand.
Before and after
Patient and plan details
- Patient: Herman Townsend, DOB 4/12/1978
- First appointment: Tuesday, May 6 at 9:30
- Office: Beechstead Chiropractic, 3110 Windshire St, Elderhaven
- Insurance: Summit Choice PPO, member ID HTW4471982, group 20877
- Verified by phone: 330-555-0132, Friday, May 2 at about 10:15, spoke with Dana
- Call reference number: 55102-88
Checklist
Coverage status
- Plan active on appointment date: Confirmed (active, started Jan 1 this year)
- End date: Not stated (Dana did not mention one)
Chiropractic benefit
- Chiropractic covered: Confirmed
- Network status: Confirmed (our office is out of network)
Visit limits
- Visits allowed per year: Confirmed (20)
- Limit type: Confirmed (calendar year)
- Visits already used: Confirmed (3)
Costs to the patient
- Copay: Confirmed ($40 per visit, out of network)
- Deductible: Confirmed ($500, fully met)
- Coinsurance: Unclear (40% after deductible, but it is not clear whether it applies on top of the copay)
- Out-of-pocket maximum: Not stated (not asked)
Referral and authorization
- Referral needed: Confirmed (no)
- Prior authorization: Confirmed (not needed for the first 12 visits)
- How long authorization lasts: Not stated
Covered services
- New patient exam: Confirmed
- Adjustments: Confirmed
- X-rays: Confirmed
- Massage: Confirmed (not covered)
- Traction: Not stated (not asked)
- Exam fees on later visits: Not stated
Claim details
- Where claims are sent: Confirmed (PO Box 8812)
- Filing deadline: Confirmed (180 days)
- Reference number: Confirmed (55102-88)
Estimated first-visit cost
We cannot give a reliable estimate yet. The notes show a $40 copay per visit, and the new patient exam fee is $95. But it is unclear whether the 40% coinsurance is charged on top of the copay, and the notes do not say how the insurer would price the exam or whether the copay already covers it. Until the coinsurance question is answered, we only know the copay is $40 per visit.
Patient summary
Mr. Townsend, your plan is active and covers chiropractic care, including exams, adjustments, and X-rays, but not massage. Our office is out of network, the copay is $40 per visit, and your $500 deductible has been met. You have used 3 of your 20 visits this year, and no referral is needed. We are still confirming how the 40% coinsurance applies and whether traction is covered. Benefits quoted by an insurance company are not a guarantee of payment.
Front desk follow-up tasks
- Call 330-555-0132 back, reference 55102-88, and ask how the 40% coinsurance applies alongside the $40 copay
- Ask whether traction is covered
- Ask about the out-of-pocket maximum
- Ask how long prior authorization lasts after the first 12 visits and how later exam fees are handled
- Update Mr. Townsend before his May 6 visit
Questions for the owner
- Do you want to quote Mr. Townsend a first-visit estimate once the coinsurance answer comes back? If so, please send the answer from the insurer.
What it does
Builds a complete checklist of what to ask an insurance company before a new patient's first visit, then turns the notes from the call into a clean benefits summary the front desk and the patient can understand. It keeps track of what was confirmed and what is still unknown.
Use it when: Use when a chiropractic office needs to prepare or complete an insurance benefits verification checklist for a new patient, such as: verify benefits for this new patient, make a benefits checklist, what do I ask the insurance company, or write up what the insurance told me.