Diagnostic Medicaid Managed Care Plan Today's Date* MM slash DD slash YYYY Patient Name* First Last HiddenPhone*HiddenEmail* Clinic*Choose a ClinicDreamShip CenterMilestones Behavioral PediatricsTrio AcademyMedicaid Insurance Coverage This patient utilizes a Medicaid Managed Care Plan for diagnostic services. For the diagnostic services listed below, patient will not have any deductible, co-pays, or co-insurance due. 90791 Diagnostic Interview 96136 Psychological Testing (1st 30 minutes) 96137 Psychological Testing (additional 30 minutes) 96130 Psychological Testing Evaluation (1st 30 minutes) 96131 Psychological Testing Evaluation (additional 30 minutes) Is prior authorization required for diagnostic services?* Yes No 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.CommentsThis field is for validation purposes and should be left unchanged.