The world of insurance has become so complicated! We hope to help you navigate this aspect of your child’s services and gain an understanding of how payment can be made for therapy.
Every insurance plan is different. Before scheduling your child’s first visit, check with your health insurance carrier to see if you are covered and learn the specifics of your coverage. Insurance plans are agreements made between you and your insurer, and Pediatric Speech and Language Specialists cannot ensure that an insurance carrier will pay for your child’s services. It is your responsibility to understand what types of coverage your health insurance provides and to be sure that you meet all requirements stipulated by your specific plan. Your health insurance carrier will be able to inform you of your level of coverage and what, if any, copayments, coinsurances and deductibles will be your responsibility.
Here are some question to ask of your insurance carrier:
- Do I need a prescription or referral?
- Do I need prior authorization or pre-certification? You or the provider may need to call in advance of starting sessions to obtain approval.
- Is there coverage for both assessment [testing and evaluation which determines diagnosis] and treatment [“speech therapy”] Does my plan provide coverage for my child’s speech therapy?
- How many visits are allowed within a calendar year under my insurance plan?
Are there any exclusions or limitations to therapy coverage? Is coverage limited to conditions that are acquired, restorative or rehabilitative which typically excludes coverage for services for children classified as “developmental” or “educational”. If relevant to your child ask if there is coverage for:
- Developmental disabilities such as: Autism, Cerebral Palsy, Down Syndrome
- Specific diagnostic categories such as: treatment for Voice and/or Stuttering Disorders
- Do I have a deductible, co-pay or coinsurance?
- Is there coverage if I use a provider who is out of network?
There are 3 options for payment of your child’s therapy:
- Private Pay
Pediatric Speech and Language Specialists is a Participating Provider with the following insurance carriers:
- Blue Cross / Blue Shield
(Note: that any insurance plans bought on the Affordable Health Care Exchange are not part of our network)
In network refers to insurance companies with whom are participating providers. Please read your benefits plan carefully. We encourage you to call your insurance carrier’s Member Services line to verify your plan’s coverage for your child’s needs.
If you are enrolled in a managed care group, such as an HMO or PPO, you might need a referral from your primary care physician. Please contact your physician for a prescription for service, including any diagnosis your child may have, before your appointment.
As a courtesy to our patients, we will obtain your benefit information from your insurance carrier prior to your first visit- only if we have your insurance card prior to your visit. If you do not send your insurance card in prior to your visit, we will call for your benefits after we get your insurance information.
Although we have verified your benefit, this is never a guarantee of payment. Limits of contracted coverage can vary widely depending upon the type of plan and levels of coverage selected. At times what is stated via the telephone prior to the evaluation in regard to benefits may vary when they see your child’s diagnostic codes after the evaluation. Some or all of the services provided in your treatment may be “not covered” services under your particular plan, and these charges are your responsibility.
The benefits booklet you have received is merely a summary of benefits and often does not contain specific contract language. It is the specific contract language which stipulates the actual conditions that have to be met in order for the benefits outlined in your plan to become available to you or your family member.
It is important to first review your health plan coverage and limitations before receiving services.
Out Of Network
Out-of-network refers to insurance companies with whom Pediatric Speech and Language Specialists is not a participating provider. This does not mean that your insurance plan will not pay for the service. Rather, it means that you – as the contract holder – need to do more of the preparation work in order to assure reimbursement. While we will make every attempt to support your insurance reimbursement, you are the contract holder. As an out of network client, it is your responsibility to pay for the services provided weekly.
As Pediatric Speech and Language Specialists does not have a contract with your insurance carrier, you must:
- Contact your insurance company in order to verify what your insurance plan allows for your child’s therapy services.
- Call our office with any requirements by your insurance company for prior authorization or documentation. Please include all necessary contact information so that we can get documentation to the insurance company in a timely manner.
Even though the client is responsible for managing their insurance provider, Pediatric Speech and Language Specialists will provide assistance. As a courtesy to you, we will electronically bill for out of network insurance.
Private pay is when the individual independently pays Pediatric Speech and Language Specialists out of pocket. You may choose to pay weekly in the office or leave a credit card on file to be billed monthly.