Understanding Insurance Coverage

Your child has been referred to us for therapy services. These therapy services are prescribed by a medical specialist or your child's primary care physician. It is your responsibility to understand your insurance coverage and obtain authorization for services.

Health insurance is obtained usually obtained through your employer.  As a health care consumer, it is important to examine the therapy benefit language of your employer's health insurance plan or call your insurance company to ask questions about your coverage. The telephone number is usually located on the back of your insurance identification card.

Where and How Do I Begin?

A sheet is available for you to utilize during your conversation with your insurance carrier.  It is designed to fill out as you ask specific questions regarding your insurance coverage.

Request Authorization for Services

• It is imperative that you contact your insurance company to ask if prior authorization or precertification is needed for occupational therapy services. If this is required, please ask the insurance company what steps are needed to obtain authorization for therapy services. The parent/legal guardian is responsible for ensuring all insurance referrals are in place from the primary care physician or specialist.
• Please note, insurance referrals and therapy prescriptions are not the same. If you have secondary health insurance, you should also check with that insurance company for therapy coverage and authorization.
• Call me with questions. Obtaining authorization for treatment can be a particularly lengthy process. You are encouraged to contact your insurance company as soon as possible following the evaluation to determine if treatment visits will be approved.
• Follow up with your insurance provider to verify that payment will be approved. Insurance companies reserve the right to deny payment for services after they have authorized visits if they do not deem the services to be medically necessary. Payment is based on medical necessity according to your plan's policy limitations. A decision to pay for services will be made by the insurance company upon receipt of the claim and will be based upon the insured 's eligibility on the date of service.

What Do I Do If Coverage is Denied?

If therapy coverage is denied, you have the following options:

• Make an appeal to your insurance carrier for reconsideration. You must contact your insurance "Member Services" department to obtain steps necessary for the appeal process.
• Talk with the evaluating therapist to explore if there are any less expensive options. (i.e., therapy on a less frequent basis with a home exercise/activity program, community-based services, etc.)