insurance appeal letters
k_janinda
InsuranceVerification-ElizabethHill.doc|
Insurance Verification Information |
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Doctor |
Williston |
C A Initials |
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Verified on |
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Patient # |
22138 |
Computer # |
7165 |
Case type |
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Patient Name |
Elizabeth Hill |
D O B |
9/17/1999 |
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Insured’s name |
Ms. Charlotte Hill |
D O B |
4/12/1970 |
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Relationship |
Mother |
Since (Date) |
9/17/1999 |
Injured / ill since |
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Employer |
VCU MCV Hospital |
Phone |
(804) 828-9000 |
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Address |
401 North 12th Street Richmond, VA |
Supervisor |
Dr. Sarah Chen |
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City |
Richmond |
State |
VA |
Zip |
21332 |
Note |
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Insurance Company |
Aetna |
Phone |
8043308340 |
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Address |
9030 Stony Point Pkwy |
Insured’s ID |
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City |
Richmond |
State |
VA |
Zip |
23225 |
Group # |
145671 |
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Contact |
Mr. George |
Title |
Claims Assoc |
Phone |
8043308340 |
Claim # |
5893-3984-1A |
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Notes |
EMO |
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Primary or Secondary insurance |
none |
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Diagnosis |
asthma with chronic obstructive pulmonary disease |
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Treatment prescribed |
Aerobid |
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Policy effective from |
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Deductible amount per year |
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Deductible met? |
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Max payment for initial visit |
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Max payment covered per visit |
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Max ceiling for X-ray and other diagnostics |
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Max number of visits covered per year |
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Items expressly not covered |
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Items requiring specific tests & confirmation |
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Other notes and comments |
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