(Adapted with permission from the Children’s Hospital of Cincinnati)
If your child has been referred or you are pursuing a speech-language evaluation or treatment, the following may be helpful in understanding the process of accessing your health care benefit program:
To request authorization for coverage:
- Call your child’s doctor: Contact the doctor who is referring your child for an evaluation. Request that a copy of the referral be submitted to your insurance company and sent to the evaluating facility or office. If your insurance company does not receive a copy of the referral before your child is seen for the evaluation, the insurance company may refuse to pay for any services and you could be responsible for payment.
- Call your insurance company: Contact your insurance company to ask if prior authorization or precertification is needed. If this is required, please ask your insurance company to fax the authorization to the evaluators office well before your appointment.
- Assistance obtaining authorization Ask if the facility evaluating your child has an insurance specialist whom can assist you in obtaining the necessary insurance authorization for the evaluation and/or speech therapy. Obtaining authorization for speech therapy can be a particularly lengthy process so you should contact your insurance company as soon as possible following the evaluation. Unfortunately some insurance plans do not cover speech or language services. Check your policy.
If your policy provides limited or no coverage for speech pathology services:
- Find out if your employer offers another plan that provides coverage for speech and language services. If so, switch to that plan during the next open enrollment period.
- Send a letter to your employer requesting better coverage in upcoming insurance plans. Employers have the greatest influence in obtaining better insurance coverage as they negotiate the contracts with the insurance companies. Your company will have no idea of the need for speech therapy coverage unless you inform them that you were denied for coverage. Group insurance coverage for speech and language evaluations and therapy is a relatively inexpensive rider for most companies to add to their existing policies.
- Inform your employer about any limitations in your plan, especially if your health insurance plan is self-insured by your employer. Your employer may be able to add speech services in future plans. Your state Department of Insurance may have limited jurisdiction over self-insured plans. With self-insured plans, the employer provides the money, decides what benefits to offer and what claims to pay. Theoretically, the insurance company just “follows orders.” The regulator over self-insured plans is the US Department of Labor, Pension and Welfare Benefits Administration at (202) 219-8776.
If coverage is denied:
If your policy lists speech pathology services as a covered benefit but you were still denied:
- Call your insurance company to determine the reason for denial. Ask for a copy of the your plan’s policy for speech therapy services and an explanation for the denial in writing. Ask the individual what is required from you to turn the denial into an acceptance (precisely what information does the insurance company need?). Write down who (you spoke with), when (time and date), and what (was said) for all telephone calls. Keep all fax confirmations.
- Write a letter to your insurance company asking them to review the claim again. A written inquiry will more likely result in a written response. The letter should be copied to your employer’s human resources officer. Include information about apraxia and its treatment. Feel free to quote the Apraxia-Kids website.
- Contact the Benefits Coordinator at your place of employment. Provide him or her with all documentation of your conversations with the insurance representative and copies of all letters sent and received. Ask your employer’s Benefits Coordinator to contact the insurance plan on your behalf.
- Appeal the decision through your insurance plan’s formal internal appeal process.See instructions below.
- Register a complaint through your state’s Department of Insurance.This is appropriate if:
- You feel that your claim is being unfairly denied. This department logs each complaint and the volume of complaints regarding a particular subject or insurance company. The department will investigate the claim.
- You are having difficulty receiving a copy of your policy. All insurance companies are required to file their contracts with this department.
- You are not getting information in a timely manner. Health Insurance Law requires insurance companies to respond to consumers in a reasonable period of time. Generally, your insurance plan is required to send you written notice of authorization within six business days of your request if your child has not begun treatment yet. If your child is already receiving treatment, the insurance company is required to inform you that you will not be covered within 35 business days.
To appeal insurance denials:
- Call your insurance company to find out how to formally appeal insurance denials for speech therapy services. Ask for a copy of the your plan’s policy for speech therapy services and an explanation for the denial in writing. Write down who (you spoke with), when (time and date), and what (was said) for all telephone calls. Keep all fax confirmations. Also, refer to your Benefits Handbook from your insurance plan.
- Find out if your plan requires a letter explaining the medical necessity for services from your child’s speech pathologist and/or pediatrician. You may also be required to obtain medical records from your referring or primary care physician. Inform your speech-language pathologist that you want to appeal the denial and if you need a letter explaining the medical necessity for services.
- Contact your child’s pediatrician or referring physician and request any necessary medical documentation and their agreement that services are medically necessary.
- Inform the Benefits Coordinator at your place of employment that you are appealing an insurance denial. Ask him/her to contact the insurance plan on your behalf. Keep copies of all documentation you submit for the appeals process. The appeal process is lengthy and generally takes 6 – 8 weeks. Find out from your insurance plan how long it is expected to take. Insurance plans should have a written policy regarding when they need to respond to appeals.
- If you have secondary health insurance, always pursue authorization for speech therapy with that plan as well.
- Ask the facility if they have any financial aid programs or are aware of sources where you can obtain secondary coverage via a state run program.
- Ask the facility if you can self-pay until the outcome of your appeal.