Insurance Verification Script

Call Goal: Determine if an out-of-network (OON) provider can see the patient without a referral and if the specific remote/telehealth services require prior authorization (PA).

Part 1: Initial Connection
"Hi, my name is [Your Name] calling from [Practice Name]. I’m calling to verify Out-of-Network benefits and authorization requirements for a patient.
Patient Name: [Patient Name]
Member ID: [Member ID]
Date of Birth: [DOB]"

Part 2: The Core Questions (POS vs. PPO)
"I see this patient has a [POS / PPO] plan. I have a few specific questions regarding Out-of-Network (OON) access:"
Referral Requirement:
(For POS): "Does this POS plan require a Primary Care Physician (PCP) referral on file to see an Out-of-Network specialist?"
(For PPO): "Does this plan allow the patient to self-refer to an Out-of-Network provider, or is a formal referral required for the claim to process at the OON benefit level?"
Prior Authorization for Specific Codes:
"Does CPT 99214 (Level 4 Telehealth) require Prior Authorization when performed Out-of-Network?"
"Does the plan require PA for Chronic Care Management code 99490?"
"Does the plan require PA for Remote Therapeutic Monitoring codes 98980 and 98981?"
Telehealth Restrictions:
"Are there any specific restrictions on the Place of Service (POS) code or Modifiers (like 95 or GT) for these telehealth and remote monitoring codes?"

Part 3: Benefit Details (OON)
"Since we are Out-of-Network, can you confirm:
What is the patient’s OON Deductible, and how much has been met?
What is the OON Co-insurance percentage?
Is the reimbursement based on the Medicare Fee Schedule or the UCR (Usual, Customary, and Reasonable) rate?"

Part 4: Closing & Documentation
"Thank you. Can I get a Reference Number for this call and your name?
Reference #: ____________________
Representative Name: ____________________"