Speech therapy is often stated as a covered benefit by most insurances, though speech therapy insurance coverage is actually highly dependent on the member’s specific plan and dictates what the employer or independently purchased plan has specified. This means two people can have Blue Cross Blue Shield insurance, but if those plans are purchased through different methods, coverage of speech-language services diagnoses will often vary.
Evaluation Coverage
The first step is to call your insurance company and ask what documentation is required to begin pursuing speech-language services. Responses will vary. Some companies will state a referral is not required, though in all cases a doctor\’s prescription is required and many providers will not initiate services without the doctor’s involvement if insurance is being billed.
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 your child needs. Remember, you are dealing with an insurance company, and the goal of insurance is to spend as little as possible. This is often done by providing misinformation to unsuspecting consumers.
When asking about coverage, ask specific questions, including the diagnostic (ICD-10) and procedure codes (CPT) covered by the plan. You will find that some insurance companies will cover the assessment, but not the therapy sessions, and others do not cover any portion of the service at all when the diagnosis is not covered.
Therapy Coverage
Many plans limit speech therapy insurance coverage for pediatric speech-language services, unless therapy is due to accident, injury, or other illness (i.e. rehabilitation). 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 they will pay for treatment of medical conditions, but will not pay for autism or developmental delays (e.g. late talkers, articulation deficits), as this is considered habilitation.
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 to appeal. 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 intake form, and your appointment is scheduled, Atlanta Speech Therapy will review the details 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.
