Behavioral Health Treatment Copayment Checklist
- Health Insurance Card.
- Treatment plan developed by your provider. Usually in your provider’s home binder.
- Information on the frequency of treatment (e.g. 2 days per week). Usually part of the treatment plan.
- Summary of Benefits for your health insurance that includes information on the plan year, copayments or coinsurance amounts, and out of pocket maximums for the individual.
- Copy of a bill/billing statement from the provider that indicates the copayments/coinsurance that you are being charged for behavioral health treatment.
- For reauthorization during plan year- information on the dollar amount applied to the copayment maximum to date