This is not an online form. Please print out as a worksheet.
OBTAINING INSURANCE PAYMENT FOR QEEG & NEUROFEEDBACK
If you want to find out whether your health insurance will pay for quantitative EEG and/or neurofeedback, you must call the insurance company and ask a series of questions. This form is designed to guide you through these questions and record the answers that you are given. Before making the call, write the diagnosis and code in the space below and have your or the patient's insurance card with you. 
 
Diagnosis: CPT Code:

When your call is answered, begin by saying, 
"I'm calling to find out what coverage I have for certain services provided by Aharon Shulimson, Ph.D., a licensed psychologist."
You will then be asked for information that is on the insurance card. You may be asked for the diagnosis. Give both the diagnosis name and code number. You should then be asked what procedure or therapy is being performed. If not, say, "I have questions about coverage for a number of procedures."

"Is Digital EEG Recording - CPT code 95816 - covered?
The charge is $350. How much will be paid?" 
$
"Is Digital Analysis of EEG - CPT code 95957 - covered?
The charge is $150. How much will be paid?" 
$
"Is Reference EEG Database Access - CPT code 99090 - covered?
The charge is $100. How much will be paid?" 
$
"Is Individual Psychotherapy - CPT code 90806 - covered?
The charge is $90. Howmuch will be paid?"
$
"Is Psychophysiological Therapy - CPT code 90876 - covered?
The charge is $90. How much will be paid?"
$
"Is Neurocognitive Rehabilitation - CPT code 97770 - covered? 
The charge is $22.50 for each 15 minutes. How much will be paid? AND is there a limit on how many 15-minute sessions can be done in a day or week?"
$
LIMIT
"Is there a limit on the number of sessions per week for any of the CPT codes that I have asked about?"
LIMIT
"Are there any other limits on my coverage for this diagnosis and these 
procedures?"
LIMIT
"Is there a deductible?"
$
"Is there an authorization number?"
#
The name of the person you spoke to:
NAME

© 2003 Aharon Shulimson Ph.D.
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