Navigating the health insurance maze can be frustrating and extremely time consuming. It can be especially exasperating to be on hold waiting to talk to an insurance representative simply to see if something your child needs, such as speech therapy, will be covered. So that you don’t have to start from scratch, to follow in a nutshell are tips and tidbits related to speech therapy coverage from various Massachusetts health insurance companies. These are meant to help you know what to do to get speech therapy covered, and to help with any decisions if you are planning to change providers and want the best match for your family's needs.
No matter which health insurance you have, some plans come with an option to access services from an out of network provider. This means that if you are currently working with a speech language pathologist who is not an approved provider for your specific health insurance company, you may still be able to get reimbursed for some of the fees. Plans vary in what they will cover out of network. They may reimburse you for 100% of the fees after a deductible is met, or they may pay a lesser percentage - this is called co-insurance. In order to secure this reimbursement, you must be up to the task of collecting and submitting invoices, and diligently following up with insurance companies.
When you submit invoices, insurance companies require that they include ICD-9, or diagnostic, codes and CPT, or Current Procedural Terminology, codes. The diagnostic code refers to the communication disorder that the speech language pathologist is treating. Some examples may be Autism Spectrum Disorder (299.00) or Developmental Expressive Language Disorder (315.31). The procedure code refers to the specific service that the SLP is providing. Some examples might be a speech/language assessment (92506) or speech/language therapy in a group setting (92508). Claims will typically be denied without these codes.
Frustratingly, when calling an insurance company, service representatives are not able to tell you the codes that you need on your invoice. However, if you have a specific code to ask about, they are usually able to tell you if that diagnosis or procedure is covered under your plan. As mentioned in a previous article, some health insurances provide speech therapy only when medically necessary. Certain diagnosis codes are related to medical necessity whereas other diagnostic codes are considered developmental or educational in nature. Therefore when submitting invoices for an out of network provider's services, it is important to understand your benefit so that you can include codes that will be covered.
There are many ICD-9 and CPT codes to choose from and your speech language pathologist will determine which codes match your particular situation. Fortunately, the American Speech-Language Hearing Association has a model invoice on their website listing CPT codes related to speech therapy. ICD-9 codes related to speech/language/hearing disorders can also be found on ASHA’s website. Direct your SLP to these links so that he or she may put the necessary information on your invoices, and you can avoid unnecessary denials of claims.
Related topics: Speech therapy and Blue Cross Blue Shield, speech therapy and Harvard PIlgrim Healthcare, speech therapy and Tufts Healthplan
Enjoy this article? Click subscribe above to receive email alerts when new articles by this Examiner are published.
Comments