Patient Name
Doe, Jane
Gender
Female
DOB
06/01/1990
Address
1505 Brookeville Way, Falls Church, VA 22043
- Results Processing
Step Therapy Info
Procedure Code
Step Therapy Required
Step Therapy Details
67028
Unknown
J1234
Yes
2 of [Antidepressants, Beta Blockers]
Provider Info
Provider name
Robert Franklin
Provider NPI
0123456789
Practice address
123 Main Street
Practice phone
833-294-6502
Practice fax
623-540-5597
tax id
32-5649812
Coverage type
In-Network
Site of service
Physician_office
Primary Insurance Info
Verified Insurance name
Aetna
policy effective date
01/01/2015
Employer Name
Apple, Inc.
provided insurance name
Aetna
policy end date
12/31/2025
funding type
Fully-funded
Member ID
W987654321
Payor phone
800-539-5837
benefits verified
careviso
Group ID
4569812
Plan name
Aetna Choice PPO II
Date Verified
04/01/2025
Active Coverage
Yes
plan type
PPO
Secondary Insurance Info
Verified Insurance name
United Healthcare
policy effective date
01/01/2020
Employer Name
ABC Solutions, Inc.
provided insurance name
UHC
policy end date
12/31/2020
funding type
Fully-funded
Member ID
75468523167
Payor phone
800-455-6278
benefits verified
careviso
Group ID
5687123
Plan name
Choice Plus
Date Verified
04/01/2025
Active Coverage
Yes
plan type
PPO
Accumulator Details
67028
In network
out of network
Deductible Remaining
$100.00
$2,000.00
Deductible Total
$2,000.00
$5,000.00
Max Out Of pocket Remaining
$6,000.00
$8,000.00
Max out of pocket total
$6,000.00
$8,000.00
Coinsurance
20%
50%
Copay
$10.00
$0.00
j12345
In network
out of network
Deductible Remaining
$100.00
$2,000.00
Deductible Total
$2,000.00
$5,000.00
Max Out Of pocket Remaining
$6,000.00
$8,000.00
Max out of pocket total
$6,000.00
$8,000.00
Coinsurance
20%
50%
Copay
$10.00
$0.00
Other Information
Date of Service
03/01/2026
Order id
a23594867902
ICD Codes
M17.0
Collection Date
03/02/2026
Linked Cases
24rv63o8drt is related to 24dn35j9amj
Attachments
No attachments
Case Comments
Collapse
BI results successful
Case History
Date/Time
Jane Doe (jack@example.com)
Created case 24dn35j9amj via portal
Date/Time
Jane Doe
Added Verified Test
Demo Product
Date/Time
Jane Doe
Added procedure codes
J1234, 67028
Date/Time
Jane Doe
Added ICD Codes
M17.0
Date/Time
Jane Doe
Changed status
open
closed