insurance appeal letters
k_janinda
InsuranceVerification-MichaelWest.docx|
Insurance Verification Information |
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Doctor |
Williston |
C A Initials |
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Verified on |
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Patient # |
22534 |
Computer # |
7153 |
Case type |
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Patient Name |
Mr. Michael West |
D O B |
7/5/1977 |
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Insured’s name |
Self |
D O B |
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Relationship |
Self |
Since (Date) |
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Injured / ill since |
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Employer |
Target |
Phone |
8042231451 |
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Address |
11105 West Broad Street |
Supervisor |
Jeffery Richards |
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City |
Glen Allen |
State |
VA |
Zip |
23623 |
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 # |
49349-399-39A |
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Notes |
PPO |
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Primary or Secondary insurance |
Aetna, no secondary |
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Diagnosis |
Allergic contact dermatitis |
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Treatment prescribed |
triamcinolone acetonide topical ointment; follow up two weeks |
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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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