insurance appeal letters
k_janinda
InsuranceVerification_GuillermoG.doc|
Insurance Verification Information |
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Doctor |
A. Patel |
C A Initials |
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Verified on |
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Patient # |
23246 |
Computer # |
1317 |
Case type |
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Patient Name |
Guillermo Gomez |
D O B |
5/3/40 |
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Insured’s name |
same |
D O B |
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Relationship |
self |
Since (Date) |
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Injured / ill since |
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Employer |
City of Richmond |
Phone |
804 3559876 |
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Address |
234 Marshall St |
Supervisor |
Mr. Irving Grimes |
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City |
Richmond |
State |
VA |
Zip |
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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 |
23235 |
Group # |
153647 |
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Contact |
Mr. George |
Title |
Claims Assoc |
Phone |
8043308340 |
Claim # |
3754-54-321-A |
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Notes |
PPO |
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Primary or Secondary insurance |
Aetna ; secondary Medicare |
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Diagnosis |
Hypertention, elevated cholesterol |
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Treatment prescribed |
Lipidor; Toprol XL |
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Policy effective from |
6/85 |
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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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