Understanding Your Policy
What kind of policy do you have?
HMO, PPO, POS, etc. Typically, HMOs require you to see a participating provider (someone that has contracted their services to that insurance company for a set fee). PPOs and POSs allow you to receive services from professionals that are “out of network.”
Check your policy booklet or call your insurance company to find out about your benefits. Look for terms like “speech therapy,” “speech-language pathology,” “occupational therapy,” “physical therapy and other rehab services,” or “other medically necessary services or therapies” to see which services are covered. Understand the limitations in your insurance policy. These may be in the form of a specific diagnosis and/or a certain number of allowed visits per year.
Is Pre-Approval Required?
Your policy booklet or your insurance representative should be able to clarify if pre-approval or a referral from your physician is needed for treatment or an evaluation. If a referral is required for pre-approval, be sure to get the referral from your primary physician before you or your child begins treatment. This referral may be a form your doctor fills out or he/she may be required to write a letter of referral. Often the insurance company will pre-certify a specific number of therapy sessions over a specific amount of time. If so, request that the pre-certification letter be mailed directly to you and keep track of the number of visits.
Keeping Good Records
Start a file and keep an accurate record of all conversations with the insurance company representatives you speak to. Always write down their full name, email address, and telephone extension number. Keep a copy of all written correspondence. Have your policy ID number handy when calling them and include it on all correspondence to the insurance company.
Submitting A Claim
If you or your child receives speech-language treatment or occupational therapy once or twice a week, claims may be submitted at the completion of each session or after a block of sessions. If more sessions are needed at the end of that time, documentation of progress may be requested by the insurance company in order to approve additional sessions. Your insurance company is required to notify you of their decision within 30–60 days. If you are told that treatment for your specific diagnosis is not covered, request the reasons in writing. This information will be helpful to have in the event of an appeal. If you are told your treatment will be covered, request that information in writing as well. Often an insurance company will consider reimbursement for services if they are medically necessary. They often deny claims that they deem educational or developmental in nature.
Always keep copies of everything you send to the insurance company in your file. Also, call the insurance company a week after you have mailed your claim, or a day after you have faxed it, to confirm that it has been received. Often reimbursement takes time; it may be a lengthy process and require you to make follow-up phone calls. If you have not heard from your insurance carrier within 2 weeks, we advise you to be proactive by contacting them and making sure they have all of the information they need to process your claim.
How Can Communication Works Help?
We will provide you with an itemized receipt that will list all of the codes necessary to seek reimbursement. The codes are defined as follows:
- ICD-10 codes are diagnosis codes**. These are individual for each person.
- CPT codes identify the procedure that occurred on the date of service.
**ICD-10 codes need to be provided by your child’s physician—this is the diagnostic reason that services are needed for the child. Written verification from a medical professional must be on file to include the ICD-10 codes on your invoices.
Other Helpful Sites
The Department of Managed Health Care Help Center is a FREE consumer assistance service for people who have been denied health care or are dissatisfied with their health plan’s decision. Contact the Help Center at 1-888-466-2219 or visit them online at HealthHelp.ca.gov.
If you plan to request reimbursement from your insurance carrier, you may find the following sample letter of medical necessity, provided by “Talk About Curing Autism (TACA),” helpful. If you do decide to pursue reimbursement through your insurance company, you may want to check the following links for helpful information. Please visit the Autism Society of America – Long Beach website, where an attorney has provided information regarding insurance reimbursement.
An additional site, AutismHealthInsurance.org, can help guide you on getting ABA and other services funded via insurance for those on the autism spectrum.
You can also read or download the California Department of Insurance- Consumer Alert regarding the new law that reconfirms health insurances must cover autism treatments.