Health Insurance Coverage Checklist

You may use this checklist as a guide when you verify coverage with your insurance company.


Reason for Test(s)

Discuss testing options with your health care provider.

No Family History (screening) ____

Follow-up Test(s) ____

Family History (please explain)

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Other (please explain)

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Your Health Insurance Information

See membership materials, e.g., member card, handbook, etc.

At the time of the test or tests, will you have health insurance coverage? Yes / No
(If No, please discuss with your health care provider.)

Name of Insured Person ___________________________________________

Member ID Number _______________________________________________

Group Number ___________________________________________________

Employer Name __________________________________________________


Health Insurance Coverage Type

HMO ___ PPO ___ Medicaid ___ Medicare ___ EPO ___ POS ___ HSA ____

Other___________________________________________________________

Health Insurance Program Name ____________________________________

Health Insurance Member Service Telephone Number __________________


Prepare for Your Call

1. Gather any information provided by your healthcare provider (e.g., family history, initial test results).
2. Call your insurance company and ask for Member Service or Customer Service (see your membership materials for the appropriate department name).
3. Ask the following questions and discuss answers with your healthcare provider.

Questions to Ask Your Insurance Company

Yes

No

Do I have cancer testing benefits?

   

Does this testing require pre-authorization by the health plan?

   

Is this testing a covered benefit under my policy?

   

Is this testing covered as a routine screening, or are there any specific criteria that must be met (i.e., family history)?

   

Is this testing subject to a deductible?

   

Will this testing be covered at 100% or will I have a cost-share or co-insurance to pay?

   

Are there any plan limitations or medical policies in place that limit testing services?

   

Telephone Call Details

Health Insurance Member Service Representative’s Name (who you talked to)______________________________________________________________

Date of Call ______________________________________________________

Call Confirmation Number _________________________________________

Notes from the Call

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