Medicare Replacement Plan Tools > Insurance Verification Type > Medicare Replacement Plan (Excluding Medica) 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 ChiropracticHonchel ChiropracticKaizen ChiropracticNemitz ChiropracticTruhlsen ChiropracticTruhlsen Chiropractic-HendricksRichard Wilson DCWeber ChiropracticWW AppletonWW BeavertonWW BloomingtonWW Burr RidgeWW FitchburgWW Flathead ValleyWW Fort MillWW Grand RapidsWW Green BayWW JacksonvilleWW LargoWW LouisvilleWW MequonWW North PhoenixWW PensacolaWW RockfordWW SpringWW WaukeshaWW Woodbury (Empower Health)Name of Insurance CompanyNote This plan is a Medicare replacement plan, which takes the place of Medicare. We do not bill to Medicare. We only bill to their Medicare replacement plan.Deductible per calendar yearHow much deductible left to meet for this year?Co-pay for Spinal ManipulationCo-insurance for Spinal ManipulationAdditional Information Exams/re-exams - not covered by Medicare Replacement Plan (but recommended to do on first visit of new diagnosis). Patient responsibility. X-rays - not covered by Medicare Replacement Plan. Patient responsibility. Therapies - not covered by Medicare Replacement Plan. Patient responsibility. Chiropractic Maximum - no chiropractic maximum per year, but has to be medically necessary. Medicare Replacement Plan can do a records review if care goes on too long. Pre-authorization - not required. Note: The Medicare allowed amount for 98941 spinal manipulation is approximately $40. If the co-pay is more than $40, patient will only be responsible for approximately $40, the Medicare allowed amount for 98941 spinal manipulation. If the patient has a co-insurance due, the co-insurance will be based on the $40 Medicare allowed amount for 98941 spinal manipulation. 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 chiropractic benefits.Need help understanding this document? Watch this short video on Medicare Replacement Plan!