Please note these are general guidelines, and this information applies to Kaufman Children’s Center specifically.

THERE IS NO GUARANTEE THAT THERAPY WILL BE COVERED BY YOUR INSURANCE COMPANY. 

When speaking to insurance representatives, it is a good idea to take detailed notes, getting full names of who you spoke to, dates of conversations, and numbers/extensions to call them back at should you have any problems or additional questions.

You may wish to start a file folder specifically for these issues.

When calling your insurance company to determine if private speech/occupational therapy is a covered benefit, they may request some or all of the following information:

• Your name, contract number, and other identifying information
• Inform them that we are a freestanding, private clinic (not a provider or hospital)
• All of our therapists are certified appropriately

POSSIBLE PROCEDURE CODES (CPT)

• Initial speech & language evaluation: 92523-GN
• Individual speech therapy: 92507-GN
• Initial occupational therapy evaluation: 97166-GO
• Individual occupational therapy: 97530-GO

DIAGNOSTIC CODES

In some cases, the insurance company may ask for diagnostic codes.  If you are already attending our facility, the diagnostic code for your child is on the lower left-hand corner of your monthly statement.  If your child has not yet been seen at our facility, explain to the insurance representative that we are unable to assign a diagnostic code without evaluating the child first.  If necessary, our office can provide you with a list of possible diagnostic codes.

At the close of your conversation, ask for the approval or reasons for rejection in writing.  Again, be certain to get the full name of the person you spoke to, with detailed notes.

Other general questions you may wish to ask:

• Under what circumstances is speech therapy covered?
• What are the restrictions (age, number of visits, percentages, etc.), if any?
• Be sure to ask if children’s developmental issues are a covered benefit. In some cases, therapy is only covered in case of an injury.

Find out how to submit claims on your own behalf, since this is not a service we provide.  Do you need a claim form?  To whom should claims be sent?  What information do you need to include?  How long will it take to get a response?

ADDITIONAL TIPS

• If your claim is denied, always appeal the decision. This can be a time-consuming and frustrating process, but persistence has been known to pay off! Often you will need to appeal more than once, but it may be worth the trouble in the end.
• Keep all correspondence from your insurance company together in one file, along with letters of support, and other documentation.
• Always document your phone calls to the insurance company, noting the first and last name of the person you spoke to, the date, and what you discussed.
• Keep copies of any letters, documentation, or anything that you send them.  Insurance companies occasionally misplace information, and you don’t want to be left without a copy of your own.
• If you call in advance to try and determine if speech/occupational therapy is a covered benefit and you get a yes response, be certain to get that person’s name. It may be helpful to send your claim directly to their attention. If you get a no response, you may wish to call back at a later time and try speaking with another person who may be more knowledgeable.  Also, even if you are told therapy is not covered, we still suggest you submit the claim by mail.
• Find out exactly why the claim was denied (ask for the denial in writing, with specifics) and resubmit addressing these issues.
• Enlist the help of your pediatrician/neurologist/other physician.  A prescription from a doctor stating that speech/occupational therapy is “medically necessary” may be helpful.
• If your claim(s) is denied on the basis of “not medically necessary,” find out exactly what criteria proves medical necessity, and who is qualified to determine this.
• From attorney Jay Trehy, Raleigh, NC: “As a general rule, any and all ambiguities in an insurance policy are construed AGAINST the insurer.  Whenever the language of a policy is susceptible to a reasonable interpretation in favor of coverage, the courts will almost always find for coverage.  The law abhors exclusions in insurance coverage.”
• Each state has a “insurance company overseer” that you may be able to file a grievance with if you have exhausted all of your appeal options with your insurance company.  In Michigan, this is through Consumer and Industry Services, Insurance Bureau Division, (517) 373-0240.

If you gather any other helpful tips along the way, please let us know so we can share them with all of our families!