More often than not, patients seeking speech and language services are denied by their insurance companies, though many insurance plans plainly state speech-language therapy is a covered benefit. Understanding your employers healthcare benefits manual is a good starting place. Further explanation of your coverage can be obtained from the benefits coordinator at your workplace.Policies may refer to treatment as speech therapy, speech pathology, rehabilitation services, speech-language, occupational, and physical therapies — it is all the same.
It is important to make note of the coverage limits and diagnosis exclusions. To better understand your policy as it relates to speech therapy, use these Talking Points to guide your conversation with your insurance company.
How to Appeal a Claim Denial
STEP 1: Review the End of Benefit Statements (EOBs) for the denial status reason. If you do not have these documents, contact the insurance company and request a written denial.
Reasons for denial often include not medically necessary, experimental treatment, not a covered service, treatment is developmental, or treatment is considered educational.
STEP 2: If coverage language (stated in manual) supports payment, an appeal letter describing the disorder, it’s medical nature and a direct reference to paragraph in coverage policy should be written. If possible, include a letter from your physician, speech-language (evaluation and/or progress report) to support medical necessity. Send all documents related to the appeal in one envelope via certified mail and fax. Submit this documentation within 30 days of denial.
Sample Appeal Letters & Additional Supports
- Education vs Restorative Sample Appeal Letter
- Stuttering Sample Appeal Letter (Fluency Disorder)
- Audiological Evaluation Sample Appeal Letter
- Hearing Aid for a Child Sample Appeal Letter
- Treatment Efficacy of Pediatric Communication Disorders (i.e. autism spectrum, phonological, language, feeding/swallowing, hearing, stuttering, cognitive-communication)
STEP 3: While waiting for the results of the appeal, contact the benefits coordinator manager at your place of employment. Share with them your conversations with the insurance company and copies of all letters sent and received. Let them know the insurance carrier has denied a needed service for your child though written policy states otherwise. Inform them that the current coverage for children with speech-language disorders is not adequate and better coverage is needed in the future. It is possible that your employer is completely unaware of the difference in policy and actual claim remittance. Also, other employees may be significantly affected by the level of coverage offered and if enough complaints are being made, your employer may consider a change in policy.
STEP 4: If the outcome of your appeal is a second denial, submit a formal complaint to your state’s insurance commissioner (Georgia Office of Insurance & Fire Safety Commissioner). The department logs all complaints and if enough families file complaints, they may decide to investigate a particular issue. You can also educate your legislators about the limitations of pediatric insurance coverage for children with special needs. Contacting local editors or newspapers and tv news outlets are also another route and making your voice heard.
STEP 5: If all else fails, living in Georgia offers you the opportunity to take advantage of a Deeming Waiver, which provides funding for therapies your child may need regardless of household income; this is funded through Medicaid. Assistance completing the necessary forms to apply is available via a FREE 2-hour seminar on Parent to Parent of Georgia’s website (scroll down to “Healthcare”). Atlanta Speech Therapy can direct you to a healthcare consultant in your area whom can complete the forms for you or review your completed forms to reduce the chances of denial.
References & Additional Information
*Cigna Speech Therapy Policy
*Aetna Speech, Voice, Dysphagia Therapy Policies
*United Healthcare Speech Therapy Policy
10 Questions to Ask When Contacting Your Insurance Company
Be the ‘Squeaky Wheel’ If Health Claim Denied
National Association of Insurance Commissioners
Appealing Claims by Janet McCarthy (powerpoint)
Employer Insurance Tool Kit
Who Are Your Local Elected Officials?