Date
Insurance Company Name
Street Address
City, State Zip
RE: Predetermination of benefits for (patient's name)
ID number: (patient's insurance identification number)
Group or Group number: (group name or number)
(Find your group and/or ID number and mailing address on your insurance card. This information allows the insurance carrier to
locate your group or individual policy and determine benefits.
Dear Insurance Company,
I am considering infertility services with Dr. (physician's name and address). My partner and I are seeking infertility services due (explain
your situation, e.g. blocked fallopian tubes, male factor, previous sterilization, unexplained infertility, etc.)
Please provide me with a written response to each question below.
- Do I have infertility benefits under my current insurance company?
- Do I have diagnostic infertility coverage allowing the physician to find the cause of my infertility problem?
- Do I have infertility treatment coverage allowing the physician to perform intrauterine insemination?
- Do I have infertility treatment coverage?
- If yes, does my policy require prior authorization for these procedures?
- If I have fertility coverage for these procedures, what is my maximum infertility benefit?
- Does my policy cover injectable medications? If yes, does my policy require prior authorization for injectable medications?
- Do I need to use a specific laboratory?
- Do I need a referral to visit Dr. (physician's name) for an initial consultation?
I would appreciate a response as soon as possible as I will be seeing my physician in the near future. Thank you.
Sincerely,
(Your signature)
