Paying For Services

The following options are available as options for payment when we are providing a service that is reimbursable by health insurance.  Not all of our services, such as consultation, workshops, etc.. are covered expenses for health insurance.

  1. Health Insurance Coverage

We encourage you to check your benefits, if using health insurance, prior to

scheduling an appointment at our office. If you call us, we will encourage you to “verify your benefits” prior to scheduling an appointment at our office.

  1. EAP  (Employee Assistance Program)

  1. Private Pay

  1. HSA (Health Spending Account)

Verifying Insurance Benefits

Use this form as a guide to verifying your insurance benefits. Before you call you will need:

Primary Mental Health Insurance Company Name: ________________________

Telephone Number (On the back of your card there is generally a website where you may be able to find out some of the needed information, although it seems to be more helpful to contact them by phone. If you do this, make contact by calling one of the numbers on the back of your card.  There may likely be a number for “Behavioral/Mental Health” and if not, a “Customer/Member Services” number.  One of the two of these should get you connected to a representative to check on your benefits.)

Phone #: _______________________

Group ID #: ______________________Member ID #: ____________________________

Primary Insured’s Name ________________________  and Date of Birth_____________

Let the representative know that you “want to verify your behavioral/mental health benefits” either for Self or that you are a Dependent.

Date Contacted: _________________Representative’s Name:______________________

Ask the following questions about your insurance benefits, if the representative doesn’t offer:

Am I In Network for this practice/office?

Solutions4Wellness, Inc.        

NPI: 1841739620        

Tax ID: 81-4201032

Yes / No

Or this provider?

Christina Diesen, LCSW        

NPI: 1326161969

Tax ID: 47-2895887

Yes / No

Or this provider?

Kim Peek, LCSW                

NPI: 1235321829

Yes / No

If “In Network”, complete the middle column, if “Out of Network,” fill in the last column.

                                        In Network Coverage                Out of Network Coverage

Is there a Deductible for Individual Sessions:

Individual Session: Yes/No

Individual Session: Yes/No

Annual effective date:

Date:_________________

Date:_________________

Amount of Deductible::

Deductible amount met as of today:

$____________________

$____________________

$____________________

$____________________

Deductible for Couples or Family Sessions:

Annual effective Date of Coverage:

Couples or Family Sessions: Yes/No

Date:_________________

Couples or Family Sessions: Yes/No

Date:_________________

Amount of Deductible:

Deductible amount met as of today:

$____________________

$____________________

$____________________

$____________________

Are the following mental health services or CPT/Billing Codes covered?

Initial Session (90791)  Yes/No

45 Min (90834)             Yes/No

55 Min (90837)             Yes/No

Family (90847)              Yes/No

Biofeedback (90901)     Yes/No

Group (90853)               Yes/No

Complexity (90785)       Yes/No

(Write below if coverage differs for out-of-network)

Is pre-authorization required for any Codes? (90837 is more routinely requiring a pre-authorization, so please verify)

Yes/No

If yes, Details:

Yes/No

If yes, Details:

What is the co-pay or percentage I am responsible to pay?

Co-pay $________ or %______

Co-pay $________ or %______

Is there a limit on number of visits per year?

Yes/No

If yes, number of visits remaining for this year ________

Yes/No

If yes, number of visits remaining for this year ________

Additional Info for “Out of Network” Benefit Inquiry:

***Important question to ask your insurance representative for out-of-network reimbursement:

“What is the process to get reimbursed for out-of-network services?

If Solutions4Wellness, Inc is an  “Out of Network Provider,” ask the representative what your financial expectation is for each CPT/Billing Codes listed above.

One other option is to ask if Solutions4Wellness can set a “Single Case Agreement”  Yes/No

“What are the steps to do so?” (we can then assist you with this).

***What is the Authorization Number for Today’s Call?                                                      Most Companies will give a number or the representative’s name and date of call. This is VERY IMPORTANT information for in the event the insurance company for some reason does not pay their portion in the manner that they tell you.

Authorization Number:__________________________________________________

**Bring this form with you to your first session with your Intake Paperwork.