What are you expected to cover or pay?

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All patients are responsible for all costs and fees that any third party payer does not cover.

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Estimated deductibles, co-pays and co-insurance are due at the time services are rendered.

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Becoming Familiar With Your Insurance:

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It is your responsibility to know the benefits of your specific insurance plan. Insurance payments for a claim are never guaranteed.

Review your insurance card: it shows you your member and group numbers/ ID, your plan type, and phone numbers to call for questions about your plan.

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It is always a good idea to obtain a reference number for every phone call with your insurance company, even when checking benefits and eligibility.

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Questions to ask when you call your insurance company

 

Speech Therapy CPT Code:

                   Evaluations: 92523

                         Sessions: 92507

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Occupational Therapy CPT Code:

                   Evaluations: 97167

                         Sessions: 97530

                                           97533

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Feeding Therapy CPT Code:

                   Evaluations: 92610

                         Sessions: 92526

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“Does my plan cover therapy?”

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“Am I responsible for a Co-Pay amount or Co- insurance?”

Copay: A fixed dollar amount you pay for certain types of care
Ex: If you have a $20 copay that is what you pay for the medical service whether the visit cost $40 or $400

Coinsurance: The percentage of the cost of the visit
Ex: if you have 20 percent coinsurance and the visit was $400 you are responsible for $80

“Do I have to meet my deductible in order for my insurance to pay for therapy services?”

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“What is my individual deductible?”

Deductible: This is the amount of money that you are required to pay in order for your insurance to start to pay towards services. Before the deductible you will most likely owe the allowed amount for each session.

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“Have I made any progress toward my deductible?”

“What will my insurance cover after my deductible is met?”

“How many yearly visits are covered for speech, feeding or occupational therapy?”

Ask if that is a "hard limit" which means that once that number is exhausted, therapy is no longer covered by insurance and anything that you pay will not go towards your deductible. If it is a soft limit we will have to request a pre authorization for sessions past the max limit.

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Does my plan have any diagnostic exclusions for speech, feeding or occupational therapy?

A diagnostic exclusion is when an insurance company will not pay for therapy if a person has specific diagnoses. Once you have a diagnosis code (from your evaluation or given to you by your doctor) you should reach out again to your insurance to check if it is covered.

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“Is pre-authorization required?”

If a pre-authorization is required this means that your insurance company places restrictions on certain medications, tests, or health services. This requires your therapist to first check and be granted permission before your plan will cover the item.

 

Private Pay

Private Pay patients are responsible for service fees in their full amount at time of service.