Cardiac Surgery Insurance Verification Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Insurance ID: _________________ Group #: _________________
• Primary Insurance: _________________ Secondary Insurance: _________________

Procedure Details

• Planned Procedure: _________________
• CPT Code(s): _________________
• ICD-10 Code(s): _________________
• Scheduled Date: _________________

Insurance Verification Checklist

Coverage Verification

• Policy Active and In Force
• Pre-authorization Required? Yes ___ No ___
• Pre-authorization Number: _________________
• In-Network Status Confirmed

Benefits Information

• Deductible Amount: $_________
• Amount Met: $_________
• Co-Insurance %: _________
• Out-of-Pocket Maximum: $_________
• Amount Met: $_________

Specific Coverage Details

• Cardiac Surgery Coverage Verified
• Hospital Stay Coverage Verified
• Post-operative Care Coverage Verified
• Device/Implant Coverage (if applicable)

Authorization Requirements

• Clinical Documentation Required: _________________
• Submission Deadline: _________________
• Authorization Valid Until: _________________

Verification Details

• Date Verified: _________________
• Staff Member: _________________
• Insurance Rep Name: _________________
• Reference #: _________________

Note: This verification is valid for 30 days from the date of verification. Re-verification may be required if surgery is scheduled beyond this timeframe.