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Insurance information for parents: Speech language therapy
Many parents choose to pursue the services of a private speech and language therapist to either set up treatment or supplement their child’s existing therapy sessions. Many of them choose to do so because supplemental therapy can often reduce the time children spend in treatment.
However, when families seek supplemental services from their health plan, they often discover the majority of private health plans will not pay for the exact services that are provided in early intervention or school settings. That is because, unlike other therapies (e.g., physical therapy), which sessions may be completely covered by your insurance, speech therapy is a whole other ball game. Consequently, below are some explanations of what speech therapy services your insurance may actually cover.
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.
Aetna U.S. Healthcare covers: Speech therapy for non-chronic conditions, illnesses, and injuries. Limits: treatment for a 60-day period per incident of illness or injury. Requires referral of PCP and prior approval by Aetna.
Other insurance providers do not explicitly state what kind of conditions will be excluded from coverage. For instance, your benefit’s handbook may state that speech therapy is a covered service; however, your plan may deny reimbursement for services based on your child’s diagnosis. Diagnoses that may be excluded from coverage include:
- Autism spectrum disorder
- Central auditory processing
- Congenital disorder (e.g., cleft lip and
- cleft palate)
- Developmental delay
- Mental retardation
- Language disorder
- Stuttering (fluency)
- My child is ____ old. Does our policy cover his speech services?
- What conditions will insurance specifically cover?
- What ICD-9 (diagnosis) codes and CPT (treatment) codes are covered for reimbursement?
- Do I need to obtain a prescription for therapy services?
- Do I need to obtain precertification for therapy services?
- Which conditions are specifically excluded from treatment?
- How many sessions will insurance cover? Is there a time limit?
- Do I have a deductible or co-pay?
- Do I need to schedule all the visits by a certain date?
- Does insurance cover out-of-network therapy services?
- How do I get reimbursed for out-of-pocket therapy expenses? What do I need to provide the insurance company with?
Denials & Appeals
If you have the speech therapy benefits and the coverage for your child’s speech and language therapy is denied, always ask for the denial in writing and try to appeal the decision using the proper appeal procedure for your insurance company. Insurance companies count on consumers not appealing decisions, and the fact is that most people don’t appeal because it’s a time-consuming hassle. Along the way, document all conversations with insurance representatives. Documentation can be very helpful for an appeal. In some states, even if you have exhausted appeal procedures within your insurance company, you can appeal to your state’s insurance commission, some of which allow for the filing of complaints online.
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