Blue Cross Blue Shield & United Health Care Benefits

Insurance Eligibility and Benefits Questionnaire

Call the member phone number on the back of your insurance card. Talk to a customer advocate and use this form to ask the right questions to determine if you have nutrition counseling benefits. Please make sure you read through this entire questionnaire with your customer advocate before hanging up the phone.

Dietitian: Aimee Senior

Practice: The Functional RD, LLC

Location: 11107 Wurzbach Suite 304 San Antonio, TX 78230

NPI 1609225333

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* 1. First and Last Name

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* 2. Date of Birth

Date

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* 3. Insurance?

Blue Cross Blue Shield

United Health Care

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* 4. Member ID Number

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* 5. Group Number

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* 6. Ask Customer Advocate: Do I have nutrition counseling benefits using procedure codes 97802 and 97803?
Blue Cross Blue Shield also provide diagnosis code z71.3

Yes - 100% with no copay, no deductible, no out of pocket, based on medical necessity

Yes - with a copay (PLEASE NOTE COPAY on Question 6)

No - "Exclusion" -- nutrition counseling is excluded on this plan

Preventative Codes Covered (United Health Care only)

Other (please specify)

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* 7. If there is a copay, how much is it? (Dollar amount or percentage amount)

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* 8. Does this plan require a doctors referral?

Yes

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* 9. Please ask customer service agent for a call reference number

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* 10. Is this a wellmed plan through United Health Care?
Note wellmed plans are not covered for nutrition counseling with Aimee

Yes

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* 1. First and Last Name

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* 2. Date of Birth

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* 3. Insurance?

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* 4. Member ID Number

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* 5. Group Number

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* 6. Ask Customer Advocate: Do I have nutrition counseling benefits using procedure codes 97802 and 97803? Blue Cross Blue Shield also provide diagnosis code z71.3

Question Title

* 7. If there is a copay, how much is it? (Dollar amount or percentage amount)

Question Title

* 8. Does this plan require a doctors referral?

Question Title

* 9. Please ask customer service agent for a call reference number

Question Title

* 10. Is this a wellmed plan through United Health Care? Note wellmed plans are not covered for nutrition counseling with Aimee

* 6. Ask Customer Advocate: Do I have nutrition counseling benefits using procedure codes 97802 and 97803?
Blue Cross Blue Shield also provide diagnosis code z71.3

* 10. Is this a wellmed plan through United Health Care?
Note wellmed plans are not covered for nutrition counseling with Aimee