Verification of Benefits.pdf
Case Note
Verification of Benefits · 07/27/2026 11:15 am MST
Initial Eval
Collect $80.00
Follow-up
Collect $15.00 for each visit
Payer and plan
Payer
Aetna (Training)
Plan name
SAMPLE THERAPY PPO PLAN
Plan type
PPO
Type
PRIMARY
Plan Eff Date
7/01/2026
Coverage status
Active Coverage In-Network Benefits
Cost sharing
Copay
$15.00
Coinsurance
N/A
Deductible and out-of-pocket
Individual deductible
$3,000.00
Individual deductible remaining
$580.00
Ind OOP
$6,000.00
Ind OOP remaining
$3,580.00
Family deductible
$4,400.00
Family deductible remaining
$180.00
Family OOP
$8,800.00
Family OOP remaining
$7,469.53
Authorization and referral
PCP
Sample PCP
PCP phone
(800) 555-1212
Auth for IE
Not reqd
Auth for Treatment
Reqd
UMO/IPA/Plan Sponsor
N/A
Referral
Required
Visits and limits
Visits remaining
13 of 50
$ limitations
N/A
Premium paid to end date
N/A
Sample data
Transaction reference: SAMPLE-520125 · NPI: 0000000000 · Tax ID: 00-0000000
