NEDA TOOLKIT for Parents
Steps to Take When Determining Coverage Allowances
Determining how much coverage your loved one has can seem like figuring out a complicated series of math
problems. By breaking the task down into simpler, more manageable tasks, you can get the job done so that your
loved one gets the care they need and you don’t get overwhelmed.
1. Obtain insurance info from patient. It is best to
get a copy of the actual insurance card.
a) Name of insurance company
b) ID #
c) Group #
d) Phone number (often labeled “MH/SA” or
“provider services” on back of card)
c) Deductible and Out-of-Pocket (OOP)
Maximum i. What are the limits and how much of
each has the patient met to date?
ii. Is the deductible included in the OOP
max? iii. Do copayments and coinsurance apply
to the deductible and OOP max?
e) Subscriber’s name, date of birth, and
relationship to patient (This is the
policyholder’s info)
3. Discuss benefits and estimated cost of
treatment with patient.
f) Employer (if it is a group policy)
4. Keep track of benefit utilization throughout
treatment and plan accordingly with patient.
g) Patient’s SSN and date of birth
h) Subscriber’s home address
2. Call insurance company to verify benefits. It
is best to record the call for future reference.
Be sure to inform the other person you are
recording. Verify the following:
a) Eligibility
i. Active policy?
ii. Effective date?
iii. Benefit year? This may be different
than the calendar year and it will affect
when the benefits renew.
5. DOCUMENT all communication with the
insurance company. It is amazing how many
times records need to be produced in order for
the claims to be paid accordingly.
a) Record phone calls if possible
b) Keep records of written correspondence
(faxes, e-mails, etc.)
c) Document the date and time of a call as
well as the name of the person you spoke
with. Also ask for a reference number if
possible. b) Benefits
i. Does the member have benefits for the
services he or she is requesting?
ii. What is the copayment or coinsurance
for each type of service/level of care
(check whatever is relevant)
iii. Is there a limit? If so, how many
sessions have been used to date?
iv. Do the sessions cross-accumulate? (i.e.
Do OP or IOP days accumulate towards
total IP or PHP days allowed?)
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