Subject: Inquiry Regarding Insurance Coverage for Autism Evaluation

Hello,

I am writing to request detailed information regarding my insurance coverage for a psychological evaluation I am considering with a provider who does not accept insurance directly. Below are the specifics of the evaluation and the provider:

 Provider Information:

• Provider Name: Dr. Duncan M. Dickson, PhD

• License Number: Colorado Psychologist License #5665

• Authority to Practice Telepsychology: APIT #14302

• Billing Provider: DMD Health, LLC, d/b/a NeurodivUrgent

• Billing Provider NPI: 1992456131

• Billing Provider EIN: 93-4485783

• Billing Provider Mailing Address: PO Box 201471, DENVER, CO 80220

 My Personal Information:

• Name: [Your Full Name]

• Date of Birth: [Your Date of Birth]

• Member ID: [Your Insurance Member ID]

Description of Services and Billing Codes:

The services for which I am seeking coverage information are part of an adult autism evaluation, detailed as follows:

• Total Evaluation Cost: [$1500 for Package A; $2500 for package B]

• 90791: Psychiatric diagnostic evaluation

• 96136: Psychological testing evaluation services by a physician or other qualified health care professional, first hour

• 96137: Psychological testing evaluation services, each additional hour

• 96130: Psychological testing, interpretation, and reporting by a psychologist, first hour

• 96131: Psychological testing, interpretation, and reporting by a psychologist, each additional hour

Reason for Evaluation:

I am considering this evaluation due to concerns related to autism spectrum disorder, and I would like to know if I have access to any out-of-network coverage that would provide reimbursement for an assessment with this provider.

Request for Coverage Information:

• What are the applicable deductibles, co-pays, or coinsurance amounts for these services?

• Is pre-authorization required for any of these services?

• Are there any limitations or exclusions in my policy that might affect coverage for these services?

Note:

Please be aware that Dr. Duncan does not accept insurance payments directly. I intend to pay out of pocket and will seek reimbursement from you according to my policy benefits. Any necessary documentation, such as a superbill, will be provided upon request.

Supporting Documentation:

Please let me know if you need any forms filled out or further information from my provider to process this request.

I would appreciate a prompt response to this inquiry as I would like to schedule the evaluation as soon as possible and need to understand my anticipated out-of-pocket costs.

Thank you for your assistance.

Best regards,

[Your Name]
[Your Contact Information]