iMotion Benefits Hub

📞 Manual Benefit Entry

Verification Info

VERIFIED BY

VERIFICATION DATE

REFERENCE NUMBER

REPRESENTATIVE

Patient Info

PATIENT NAME

DATE OF BIRTH

MEMBER ID

HEALTH PLAN

PLAN NAME

COVERAGE STATUS

FUNDING TYPE

EFFECTIVE DATE

IN-NETWORK

COPAY

CO-INSURANCE %

DEDUCTIBLE (IND)

DEDUCTIBLE MET

DEDUCTIBLE REMAINING

OOP MAX (IND)

OOP MET

OOP REMAINING

VISIT LIMIT

VISITS REMAINING

AUTH REQUIRED

OUT-OF-NETWORK

COPAY

CO-INSURANCE %

DEDUCTIBLE (IND)

DEDUCTIBLE MET

DEDUCTIBLE REMAINING

OOP MAX (IND)

OOP MET

OOP REMAINING

DISCIPLINE

📋 Paste Your Benefit Notes Here

Paste your filled template below, then click Generate VOB. Recognized values will fill the benefits table. Extra notes will appear on the VOB.

⚠️ Reminder: Eligibility verification is NOT a guarantee of payment. Verify coverage before treatment. Double-check values against original ASH PDF.

🦵 Physical Therapy

🖐 Occupational Therapy

💬 Speech Therapy

📝 Prompt Entry Guide — PT Enter each value into Prompt → Edit Patient Insurance

📋 Policy Notes — Ready to Paste into Prompt

👆 Click Copy All, then paste into the Policy Notes field inside Prompt.

Additional Notes for VOB