Insurance Coverage Worksheet: This quote may not guarantee benefits or coverage. You and CNY can be misquoted benefit information. Insurance Company: ______________________
Policy/Member ID #: _____________________
Who is covered under the policy: ☐ self ☐ partner ☐ both Who is the policyholder? ☐ self ☐ partner ☐ I am a dependent under ___________(name) ______(date of birth) *Is this your ONLY active medical insurance? ☐ YES ☐ NO *If no, is this policy PRIMARY or SECONDARY. If you have two insurance policies, you must provide our office with both the primary and secondary insurance information. Failure to supply the office with your primary insurance will result in full denials by your secondary insurance and patient responsibility. Is a Referral Required from my Primary Care Physician? ☐ YES ☐ NO What is my Deductible: $___________ How much of my deductible have I met this year? $ _________ as of (date) ___ /___ /___ Do I have an ‘out of pocket maximum’: $___________ Do I have a Co-Pay per visit: $_______ for Specialist Office Visit $______ for bloodwork/ labs $_______ for radiology/ultrasounds Do I have to pay a % of my diagnostic testing and office visit(s) once my deductible is met? _______% Is there a preferred laboratory I should go to for bloodwork? ☐ Lab Corp ☐ Quest ☐ Other:_________ *If your insurance requires use of specific lab, you must notify our office in advance of each bloodwork appointment. CNY Fertility routinely sends bloodwork to LabCorp. If LabCorp is not in your insurance network, you may have additional costs. Does my policy have an Infertility Age Limit? ☐ YES _____________ ☐ NO Is the CNY Fertility location of choice, ‘IN NETWORK’ with my policy? • If no, do I have out of network benefits?
☐ YES ☐ YES
☐ NO ☐ NO
If I do have out-of-network benefits, do I need to pay a higher percentage of my care? ☐ Yes ___ % ☐ No While speaking with your insurance company, they may ask for a billing (CPT procedure) code. This is a 5-digit code used by the insurance company to determine if something is covered. We have included those CPT codes for services below. Please use this as a guide to explore your coverage. Below are the commonly used diagnosis codes for testing and/or during a cycle. • Common diagnosis code used for DIAGNOSTIC/PRECONCEPTION TESTING orders: o Z31.41 Procreative Management/Testing or N97.9 Female Infertility • Diagnosis code used for all monitoring services with IUI/IVF/FET cycles and with all IUI/IVF/FET procedures: o Z31.83 Encounter for ART procedure cycle
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