Medicare Primary, Commercial Insurance Secondary Tools > Insurance Verification Type > Medicare Primary, Commercial Insurance Secondary Today's Date* Date Format: MM slash DD slash YYYY Patient Name* First Last Phone*Email* Clinic*Choose a ClinicBalanced Living ChiropracticComplete Balance ChiropracticCoulee HealthErickson ChiropracticGregory Bernard ChiropracticHonchel ChiropracticKaizen ChiropracticNemitz ChiropracticTruhlsen ChiropracticTruhlsen Chiropractic-HendricksRichard Wilson DCRiverside ChiropracticWeber ChiropracticWW AppletonWW BeavertonWW BloomingtonWW Burr RidgeWW Flathead ValleyWW Fort MillWW Grand RapidsWW Green BayWW JacksonvilleWW LargoWW LouisvilleWW MequonWW North PhoenixWW PensacolaWW RockfordWW SpringWW WaukeshaWW Woodbury (Empower Health)Important Information This patient has Medicare as primary, and Commercial insurance as secondary. We will show the Medicare benefits. We will show the Commercial Insurance benefits. We will show how the Commercial Insurance will coordinate with Medicare.Medicare is PrimaryClinic’s Participation StatusParticipating provider with MedicareNon-participating provider with MedicareMedicare DeductibleMedicare DeductibleHow much deductible left to meet for this year?Important Information Co-pay for 98941 spinal manipulation - between $7.60 to $8.30 (The co-pay amount is different for each doctor each year). Exams/re-exams - Not covered by Medicare (but recommended to do on first visit of new diagnosis). Patient responsibility. X-rays - Not covered by Medicare. Patient responsibility. Therapies - Not covered by Medicare. Patient responsibility. Chiropractic Maximum - No chiropractic maximum per year, but has to be medically necessary. Medicare can do a records review if care goes on too long. Pre-authorization - Not required Important Information Deductible left to meet for this year - Patient pays clinic in full for charges. Medicare sends any payment to patient. Co-pay for 98941 spinal manipulation - Patient pays clinic in full for charges. Medicare sends payment to patient. Exams/re-exams - Not covered by Medicare (but recommended to do on first visit of new diagnosis). Patient responsibility. X-rays - Not covered by Medicare. Patient responsibility. Therapies - Not covered by Medicare. Patient responsibility. Chiropractic Maximum - No chiropractic maximum per year, but has to be medically necessary. Medicare can do a records review if care goes on too long. Pre-authorization - Not required Commercial Insurance that is SecondaryName of Insurance CompanyClinic isChooseIn NetworkOut of NetworkIn Network BenefitsIndividual DeductibleAmount per yearHow much deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/DayFamily DeductibleAmount per yearHow much deductible left to meet for this year?Insurance BenefitsAre the insurance benefits for spinal manipulations, exams, x-rays and therapies the same?YesNoCo-insurance/co-pay that patient must pay per visitAfter deductible is met:Choose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurace/co-pay due% of the allowed in network rate?Dollar amount?Spinal Manipulations - After Deductible is MetCo-insurance/co-pay for spinal manipulationChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate?Dollar amount?Exams/re-exams - After Deductible is MetCo-insurance/co-pay for an exam/re-examChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate?Dollar amount?X-rays - After Deductible is MetCo-insurance/co-pay for x-raysChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate?Dollar amount?Therapies - After Deductible is MetCo-insurance/co-pay for a therapyChoose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the allowed in network rate?Dollar amount?Chiropractic MaximumChiropractic maximum type per yearChooseVisit limitDollar amount limitNo chiropractic maximum per year, but has to be medically necessary.Amount of Chiropractic maximumAmount of Chiropractic maximumAmount of Chiropractic maximum left to use this yearAmount of Chiropractic maximum left to use this yearPre-AuthorizationIs pre-authorization required for chiropractic care?YesNoIf yes, what are the procedures for this?ChooseProvider needs to submit clinical submission form to insurance.Pre-authorization informationPre-authorization InformationOut of Network BenefitsIndividual DeductibleAmount per yearHow much deductible left to meet for this year?DeductibleChooseRuns on a calendar yearRuns on a plan yearPlan year runs fromMonth/Day to Month/DayFamily DeductibleAmount per yearHow much deductible left to meet for this year?Insurance BenefitsAre the insurance benefits for spinal manipulations, exams, x-rays and therapies the same?YesNoCo-insurance/co-pay that patient must pay per visitAfter deductible is met:Choose% of the allowed in network rateDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount?Dollar amount?Spinal Manipulations - After Deductible is MetCo-insurance/co-pay for spinal manipulationChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount?Dollar amount?Exams/re-exams - After Deductible is MetCo-insurance/co-pay for an exam/re-examChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount?Dollar amount? X-rays - After Deductible is Met Co-insurance/co-pay for x-raysChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount?Dollar amount?Therapies - After Deductible is MetCo-insurance/co-pay for a therapyChoose% of the charged amountDollar amountBoth co-insurance and co-pay dueNo co-insurance/co-pay due% of the charged amount?Dollar amount?Chiropractic MaximumChiropractic maximum type per yearChooseVisit limitDollar amount limitNo chiropractic maximum per year, but has to be medically necessary.Amount of Chiropractic maximumAmount of Chiropractic maximumAmount of Chiropractic maximum left to use this yearAmount of Chiropractic maximum left to use this yearPre-AuthorizationIs pre-authorization required for chiropractic care?YesNoIf yes, what are the procedures for this?Coordination of Benefits between the two insurancesWill the commercial insurance cover the Medicare deductible?YesNoWill the commercial insurance cover the Medicare co-insurance for spinal manipulations?YesNoIf no:Will the commercial insurance cover exams/re-exams that Medicare will not cover?Yes, see the amount that commercial insurance will pay for examsNoWill the commercial insurance cover x-rays that Medicare will not cover?Yes, see the amount that commercial insurance will pay for x-raysNoWill the commercial insurance cover therapies that Medicare will not cover?Yes, see the amount that commercial insurance will pay for therapiesNoAdditional 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 chiropractic benefits.Need help understanding this document? Watch this short video on Medicare Primary, Commercial Insurance Secondary!