ABA Commercial Exclusion and Medicaid Today's Date* Date Format: MM slash DD slash YYYY Patient Name* First Last Phone*Email* Clinic*Choose a ClinicDreamShip CenterMilestones Behavioral PediatricsTrio AcademyPrimary Insurance CoverageName of Insurance CompanyThis Insurance Company does not have coverage for ABA therapy. There is an exclusion on the policy for ABA therapy. Since the patient does not have any ABA therapy benefits with their primary insurance, we can bill to Medicaid as secondary, letting Medicaid know that the primary insurance doesn’t cover ABA therapy.CommentsSecondary Insurance CoverageInsurance Company is Forward Health Medicaid. Patient has active coverage with Forward Health. Patient has regular Forward Health coverage for ABA therapy (full coverage) as secondary. For ABA therapy, patient will not have any deductible, co-pays, or co-insurance due. Prior authorization is required for ongoing ABA therapy with Forward Health. Prior authorization tips: In this situation in which there is no coverage for ABA therapy with the primary insurance, the clinic will just treat this patient like a straight Medicaid patient, using all of the regular Medicaid modifiers when completing the prior authorization. If patient does not have an autism diagnosis, it is possible that the Forward Health prior authorization may not be approved. It is up to the clinic to decide if they want to begin care with this patient before the prior authorization is approved.Coordination of BenefitsChoose OneThe primary insurance listed above is correctly listed as the primary insurance according to Forward Health.Forward Health does not know about the patient’s primary insurance coverage. The parents must notify Forward Health of the patient’s primary insurance coverage so that Forward Health knows about it and lists it as primary commercial insurance on file.Forward Health lists a different commercial insurance as primary. The parents must notify Forward Health and update their coordination of benefits with Forward Health, letting them know about the new commercial insurance that patient has.Additional CommentsDisclaimer When we call on a patient's insurance and verify benefits it is not a guarantee of payment by the insurance company and may vary according to the patient's individual plan when the actual claim is submitted. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at time of service. The patient responsibility amount provided is an estimate of cost. The patient must understand that their health insurance company may deny payment for the services received. The patient must understand that it is ultimately the patient's responsibility to contact their insurance if they want to know exact benefits.PhoneThis field is for validation purposes and should be left unchanged.