Policy Details

Insurance

Policy #

Effective Date

Group

Stop Date

Claim

Plan

Verify Date

Days Remaining on High RHC Rate

Comments

Insured

Pt Relation to Insured

Insured Name

Employer

Insured Employer

Employment Status

Preferred Providers

Homecare Agency

DME Company

Guarantor

Relationship to Patient

Street Line 1

SSN

Name

Street Line 2

Gender

M F

City

Home Phone

Ext

State

Zip

Coverage

Contact

HH Benefits

Yes No

Max Episode $

Phone

Ext

% Coverage

Max Episode Days

Date

Effective Date

Max Lifetime $

Copay

Deductible

Max OOP $

1st Cert Considered

Deductible Met

Yes No

Remaining $

Restrictions

No Fault Benefits

Yes No

Compensation

Yes No

Exclusionary Clauses

Billing Documentation

Private Duty Coverage

PD Billing Documentation

Services

Services Covered

Nursing

Shift Nursing # hrs

HH Aide # hrs - A.M.

HH Aide # hrs - P.M.

Shift Nursing Level

Case Manager

Case Managed

Yes No

Case Manager

Phone

Ext

Fax

Billing Changes

Submission Error

Yes No

Eligibility Change

Yes No

Private Insurance does NOT cover services

Yes No

MCR Denial - Service

Date Effective

Last Billable Visit Date

Other Billing Change

Policy Sequence

Add a new Policy Sequence?

Bill Rates

All charges use gross rate

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Eligibility Request Log