Enrollment Form

Question 1

Reimbursement is made up of what three components?

Answer 1

• Coverage-means whether the product or service is covered
• Payment-The amount the provider is paid
• Coding-product service written in code

Question 2

What are the enrollment form sections? (Sections 1.1-4.3)

Answer 2

Section 1.1 
 • Physician requested     info.=info. requested by the physician regarding benefits 
Section 2.1
• Patient information 
• Ex: Social Security #, DOB, demographics
Section 2.2
• Insurance info for the patient
Section 3.1
• Treatment info (diagnosis)
Section 4.1
• Doctors prescribing info.
• Ex: NPI, doctors license, and doctors office info.
Section 4.2
• Office contact info (site coordinator)
Section 4.3 & 4.4
• Physician certification=physicians sig and date
• Phy sig required (can be electronic)

Question 3

What are the enrollment sections? (Sections 5.1-6.3)

Answer 3

Section 5.1
• Patient diagnosis code
Section 6.1
• Patient name and preferred language
• Sig. required-(sig of patient not required if Dr. electronic sig is on file)--
Section 6.3
• Patient authorization 
• (Sig of patient not required if Dr electronic sig is on file)
Section 6.4
• Physician sig and date

Question 4

Which sections require a phy sig?

Answer 4

Sections 4.3, 6.1, 6.3

Question 5

Reimbursement verification

Answer 5

• Contact- Payer to determined patient cost
• Verify – Patient coverage
• Navigate