Insurance Coverage Basics

Assessment Coverage

Typically, parents don’t usually seek out speech language pathologists before consulting with other relevant professionals, such as pediatricians and child psychologists. In the majority of cases, it is usually the pediatrician who gives a referral for speech therapy services, or at least for a speech language assessment.

It is important to note that most insurance policies will cover (partially or completely) initial speech and language evaluations, even if the speech therapist is out of network. The first step is to call your insurance company and ask them what documentation is required to receive assessment coverage. Here, depending on your insurance company, responses might vary. Some insurance companies require a written prescription from the doctor coupled with the precertification interview with the treating speech therapist. Typically, the utilization management division of the insurance company deals with the precertification interview. After precertification takes place, make sure to ask your insurance representative about coverage for out-of-network therapists. Please note that many private practitioners don’t accept insurance. They will instead provide you with a letter for your insurance company containing the necessary diagnosis and treatment codes, incurred fees, as well as a brief description of services provided, and will expect you to apply for reimbursement on your own.

Note: Parents should not assume that if assessment is provided in an outpatient hospital setting, their health insurance will pay the bill. In many cases, insurance denials result in parents having to pay the full cost of the services provided.

The first step to insurance coverage for assessment is to speak to the insurance representative directly, even if your service provider had already done so for you. Parents are encouraged to take this extra step to avoid any misunderstanding and confusion, which may lead to costly errors. Just asking if you are covered for “speech” therapy is not enough to determine if you are covered for the specific treatment you need. Therefore, when asking about coverage, you want to ask which diagnostic and procedure codes your speech therapist should list to help ensure the codes used accurately reflect the coverage you have. It is always better to learn and clearly understand information firsthand rather than from a third party, especially because the same coverage that pays for assessment may not cover therapy services—a fact that baffles and outrages many of the parents.

To reduce confusion, take detailed notes during all conversations with the insurance company. You may get conflicting information from different people at the insurance company, so it will be important for you to write everything down as you move through this process. Always note the date and time of your phone calls, as well as the name, phone number, and department of the people you speak with and their exact responses to your question.