Insurance Coverage Questionnaire - BKD.com

Insurance Coverage Questionnaire Resident Full Name _________________________________________________ DOB ___/___/____ SSN ____-____-_____

□Male

□Female

Medicare Number _________________________________ Projected Admission Payor

Medicaid Number ____________________

□Private Pay □Medicare A □Medicaid □Medicaid Pending □Insurance

□ Other (define) ___________________________________________________________________________ Insurance Verification Insurance Company 1 (Be Specific) ______________________________________________________________ Phone # ____-____-____ Insurance Contact Name ______________________ Group # ________________ Policy Holder Name ____________________________________ Policy #_____________________________ Billing Address ________________________________________ Authorization # ______________________ Deductible Amount $ _______ □Met □Not Met Coverage Room/Board Copay ________________________ Ancillary Copay ______________________ Is hospice or HMO primary over Medicare? If HMO primary, how do they reimburse?

□Yes □No □Levels □RUGs

□Total Charges

□ Other (define) ___________________________________________________________________________ Insurance Company 2 (Be Specific) ______________________________________________________________ Phone # ____-____-____ Insurance Contact Name ______________________ Group # ________________ Policy Holder Name ____________________________________ Policy #_____________________________ Billing Address _____________________________________________ Authorization # __________________

□Met □Not Met Deductible Amount $ _______ Coverage Room/Board Copay ______________________ Is hospice or HMO primary over Medicare? If HMO primary, how do they reimburse?

Ancillary Copay ______________________

□Yes □No □Levels □RUGs

□Total Charges

□ Other (define) ___________________________________________________________________________ Name of Previous Employer (If Known) ___________________________________________________________ Are either of these insurance policies related to the Employer’s continued plan?

□Yes □No

Medicare Coverage Med A – Day Available ___________ Med B – Therapy Used _____________________ Admission Information Admission Date ___/___/____ Admitting Diagnosis ________________________ ICD10 Code ________ Primary Physician Name ___________________________________________________ NPI # _____________ Admitted From ___________________________ Inpatient Hospital Dates _____________________________ # of SNF Days Used in Hospital ___________ Other SNF Days Used ________ SNF Name __________________ Date of Accident/Incident (See MSP Quest) ___/___/___ Location of Accident/Incident _________________ Completed By ____________________

Date ___/___/___

Attach copies of Medicare, Medicaid and insurance cards