FINANCIAL SERVICES

Shady Grove Fertility

INSURANCE BENEFIT QUESTIONNAIRE

Before every new patient appointment at SGF, our benefit verification team works to confirm each patient’s insurance coverage. We
also encourage our new patients—or current patients with new insurance coverage—to contact their insurance company prior to their
appointment to confirm coverage for the diagnosis and treatment of infertility. Having both parties investigate the insurance coverage
expedites the overall process and identify any erroneous information. At the new patient consultation, the patient and financial
counselor will review their findings regarding insurance benefits and coverage.

This guide will help patients better understand the important questions to ask their insurance provider when investigating the details of
their policy. This information is not a guarantee of coverage and is not an authorization. Claims must be submitted and reviewed prior to
any payment.

1. Is the physician/Shady Grove Fertility listed as a participating provider? Yes___________ No___________

2. Do I need a PCP referral to be seen by the doctor? Yes___________ No___________
3. Will my visit require insurance authorization? Yes___________ No___________
4. Do I have coverage for testing to diagnose the cause of infertility under diagnosis code Z31.41? ___________
a. If yes, what is my co-pay/co-insurance for diagnostic office visits? ___________
b. Do I owe anything above and beyond my co-pay for diagnostic office visits? ___________
5. Do I have coverage for treatment of infertility under diagnosis code N97.9? ___________
a. If yes, are there specific criteria that must be met prior to accessing this coverage? ___________
b. Do I have coverage for artificial insemination (IUI) (CPT codes 58322, 58323, Z31.89)? ___________
c. Do I have coverage for in vitro fertilization (IVF) (CPT codes 58970, 58974, Z31.83)? ___________
d. If yes, what is my co-pay? ______________________
e. If yes, what is my coinsurance? ______________________
6. Is there a lifetime max that is associated with the infertility benefit? Does this lifetime max include both treatment
and medications?
a. If so, how much is it and how much is remaining? __________________________________
b. Are there any attempt limitations for IUI or IVF? (Example: 3 attempts per lifetime) __________________________________
c. Are there age limits or other limits for specific treatments? __________________________________
7. What is my annual deductible?______________________ How much is remaining for the current year? ______________________
8. Is pre-authorization required for any of the following:
a. Diagnostic testing (lab or radiology)? __________________________________
b. Treatment procedures performed in the office? __________________________________
c. Oral/injectible fertility medications? __________________________________
d. Obstetrical/medical sonograms performed in the office? __________________________________
9. Is pre-certification required for services performed in an Ambulatory Surgery Center? __________________________________
10. What is my coverage for "specialty injectible" medications for infertility? (examples: Ovidrel, Gonal–F, Bravelle,
Follistim) __________________________________

Per: _________________________ Date/Time: _________________________ Phone #: _________________________ Reference#: _________________________

GEORGIA | MARYLAND | PENNSYLVANIA | VIRGINIA | WASHINGTON, D.C. | SHADYGROVEFERTILITY.COM

OCTOBER 2017