Speech therapy is often stated as a covered benefit by most insurances, though coverage is actually highly dependent on the member’s specific plan. This coverage is often dictated by what the employer has specified. This means two people can have Blue Cross Blue Shield insurance, but if those plans are purchased through different employers, coverage of speech therapy diagnoses will often vary.
The first step is to call your insurance company and ask what documentation is required to get assessment coverage. Responses will vary. Some insurance companies will require a written prescription (referral) from the doctor. Typically the utilization management department (authorizations) of the insurance company handles these matters.
Parents are encouraged to be proactive in this process. Just asking if you are covered for “speech” therapy is not enough to determine if you are covered for the specific treatment you need. When asking about coverage, ask specific questions, such as which diagnostic (ICD-10) and procedure codes (CPT) are covered by the plan.
You will often find insurance companies will cover the assessment but not the therapy sessions.
Most speech therapy coverage is very limited for pediatric speech-language pathology services unless need for therapy is as a result of accident, injury, or other illness. Some policies exclude children by age and/or others refuse to cover school age children because they are expected to receive speech-language services in school settings. Other policies may state that they will pay for treatment of problems related to medical conditions, but will not pay for autism or developmental delays (e.g. late talkers, articulation deficits).
Speech & Language Services and Autism Spectrum Disorder
When seeking speech language services for children diagnosed with Autism Spectrum Disorders, over 35 states provide insurance coverage. In Georgia this law is called Ava’s Law. Information related to other states can be found here.
Denials and Appeals
If you are denied coverage, always ask for the denial in writing. This document will state the denial reason and you will use that to follow your insurance’s appeal procedures. Insurance companies count on consumers not appealing decisions; and the fact is that most people don’t do it because it is time consuming.
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. We’ve detailed How to Appeal a Speech Therapy Insurance Denial on our blog which includes sample letters, etc.
After you have submitted your case history form, Atlanta Speech Therapy will review the specifics of your insurance policy online and/or contact your insurance company to determine your plan benefits and provide you with an estimate of costs prior to your first visit to our office.
What specific questions should you ask your insurance carrier?
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