Practice Name: Reunion Audiology LLC

Provider: Stefan Marchant, Au.D

License Number: TX 81012

NPI: 15-88177307

EIN: 92-3428955

Practice Name: Wichita Falls Hearing

NPI: 1427664622

Tax ID: 851855501

Insurers

Aetna: 800-872-3862

Insurance Verification Outcome

Patient Info

For BCBS, most of this information can be obtained through automated system. You may have to have it repeat, if you don't list closely. The form is laid out in the order that benefit details are given for BCBS automated system, since they are the most problematic time wise.

If they ask for codes to look up:

V5261 = Binaural BTE

92557 = Comprehensive Test

Carrier Info

Policy Details

Deductible

$
$
$
$

Out of Pocket

$
$
$
$

Hearing Aid Coverage

Allowed Amount (In Network Only)

Billed Charges = % of Invoice Amt

Benefit Max = Defined Max Benefit

Third Party = Only Usable through 3rd party provider

No Benefit = No Hearing Aid Coverage

Only if type is third party
$
$
Reguired if there is a benefit
Can the benefits be used now?

Testing Coverage

$

Primary Care Physician

If referral or prescription from PCP is required for benefit use.

Verification Details

Fill this part out even if there are no benefits. If benefits were acquired through Availity/Automated System, specify in reference number field.