Insurance Reimbursement

Insurance Reimbursement

Helpful Hints for Insurance Reimbursement

Depending upon your insurance policy, speech-language therapy may be a covered benefit. Benefits vary greatly from policy to policy so it is important to take the time to become acquainted with your individual benefits. Although Speech & Language Specialties is not a participating provider with any insurance carriers, we will support you by providing appropriate documentation of the speech-language services received at our center. We have compiled some helpful hints to assist you in your quest for reimbursement.

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", "physical therapy and other rehab services" or "other medically necessary services or therapies" to see if it is a covered service. Understand if there are any limitations in your insurance policy. These may be in the form of specific diagnosis and/or certain number of visits per year.

Is Pre-Approval Required?

Your policy booklet or your insurance representative may clarify if a referral or pre-approval 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 the pre-certification letter be mailed directly to you so that you may 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 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 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 will be helpful to have in the event of an appeal. By the same token, 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.