Page 67 - R2P Front Desk Manual v1

Insurance Verification Template

Rep will ask for the following information:
Facility from which you are calling? Rehab 2 Perform
Facility address & return phone number?
TAX ID: 462646543
NPI: 1306251434 *you may need to provide a specific PT's NPI # (if so, reference Staff Demographics document in Info Drive)
Your first name and last initial?
Reason for your call? Benefits for physical therapy in the OFFICE setting
Are we in network? Yes (or no) for ones we know; if unsure, you can ask the rep to check if we are in or out
Do we participate with our local PPO plan? Yes
Are we HMO participants? Yes
Do we bill as professional or facility? Professional

Patient Name
Date of Birth
Insurance Carrier
Member ID#
Group #
Provider Phone #
Plan Type
Current Effective Date
Benefit Period Calendar Year Policy Year Start: End:
Subject to Deductible? Yes No
Individual Deductible $ Amount Applied $ Deductible Met? Yes / No
Family Deductible $ Amount Applied $ Deductible Met? Yes / No
Coinsurance % / % after deductible has been satisfied
Individual OOP $ Amount Applied $ OOP Met? Yes / No
Family OOP $ Amount Applied $ OOP Met? Yes / No
Copay Amount $ *Some plans have a copay amount after the deductible has been satisfied (instead of a coinsurance)
# of Visits Allowed PT only combined per cal / plan yr
Visits Per Condition? Yes No
# of Visits Used *If per condition, need to know # of visits used per diagnosis code or body part - ask rep & patient to confirm
Referral Required? Yes No
Pre-auth Required? Yes No If yes, type of pre-auth required:

Representative Name
Call Reference #
Date Verified