Behavioral Health Treatment Copayment Checklist

Announcement

Documents needed:

  • 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