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Determination of Benefits Check

For any questions, please contact ARPwave via phone at (952)431-9708 or via email at [email protected]

Today's Date (mm-dd-yyyy)

Patient's Name *

First

Last

Patient's Date of Birth

Patient's Email Address

Patient's Home Phone Number

Patient's Cell Phone Number

Patient's Insurance Provider/Company

ID Number

Doctor/Provider Name *

Doctor's NPI Number

Doctor's Tax ID Number

Does the Paitent have Active Insurance

Is the Doctor In-Network

Patient's Deductible

Has the Patient Met Their Deductible

If No, Amount Remaining in Deductible

Has the Patient Met Their Family Deductible

If No, Amount Remaining in Family Deductible

Out of Pocket Info (OOP)

Individual Out of Pocket Amount (OOP)

Individual Out of Pocket Remaining (OOP)

Family Out of Pocket (OOP)

Family Out of Pocket Remaining (OOP)

Co-Insurance Percentage

Co-Pay Amount Per Visit

Does the Patient Have Therapy Benefits

Policy Coverage - How Many Therapy Visits Per Year

Is This a Hard Max

How Many Therapy Sessions Have Been Used This Year

How Many Therapy Sessions Remain This Year

When Does the Policy's Benefit Year Renew

Does the Patient's Policy Cover Code

97162
97530
97112
97110
97032
90901
96000

Select All That Have Coverage

Does the Patient Need Prior Authorization

Documents Requested for Prior Authorization

Doctors Notes
Therapy Rx
Medical History or Physical
Operative Report
X-Ray Reports
MRI Reports
Ultrasound Report

Select All That Have Been Requested or Provided

Number of Visits Required

ICD-10 Code

ICD-10 Code

ICD-10 Code

ICD-10 Code

ICD-10 Code

Approved

Authorization or Approval Number

Call Reference Number

Notes

Does the Patient's Policy have Out-of-Network (OON) DME Benefits

Patient's OON Deductible

Has the Patient Met Their DME Deductible

If No, Deductible Amount Remaining

Does the Patient's Policy Cover DME Code

E0764 - Funt. Neuro Muscular Stim: $2,300/mo
E0745 - Neuro Muscular Electrical Stim: $990/mo
A4556 - Self Adhesive Electrodes: $918 - 40 unit

Select All That Have Coverage

Does DME Require a Prior-Authorization

Prior Auth - Fax Submission Number

If Prior Authorization is Required

Additional Notes

DME Authorization or Approval Number

DME Reference Number

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