Speech Therapy and Insurance Coverage- Top 10 Questions to Ask Your Insurance Carrier

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Speech-Therapy and Insurance Coverage-Top 10 Questions to Ask


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By, Adrienne Frohlich, M.S., CCC-SLP


Most health insurance plans offer some coverage for speech-language therapy services, however there are many potential restrictions or limitations to this coverage. Coverage may not only vary between different insurance carriers, but also among specific plans within a company.  The first question to consider, is whether speech therapy is a covered benefit. If so, your policy should specify a number of sessions that you are entitled to, either per calendar year, or other time frame, or per diagnosis. There may be a lifetime limitation on the total number of sessions you, or your child can receive. The total number of sessions may be combined with physical or occupational therapy as well.

Some plans may cover an evaluation or testing to obtain a diagnosis but will not cover treatment.
Even if speech therapy is a covered benefit, there are some common conditions that may be automatically excluded, such as developmental speech or language delays. This may or may include conditions such as Cerebral Palsy, Autism or Down Syndrome. There may be exclusions for what is not considered ‘medically necessary’ and this may vary from plan to plan.
If you are unsure about your coverage, or want to ensure that services will be covered prior to beginning therapy, you should speak with someone at your insurance plan. It helps to be prepared and understand some of the terminology that is involved.

The following questions may be helpful in determining coverage.

1.   Does my policy cover speech therapy services?

2.    Are there any conditions that are specifically covered or excluded?  These may be a list of diagnosis codes, also known as ICD-9 codes (typically a 3 -5 digit number, i.e. 315.39)

3.  What treatment codes are covered?  A treatment code also known as a CPT code is 5 digits (i.e. 92507) and may determine whether an evaluation or treatment is covered.

4.   Do I need a prescription or referral?

5.    Do I need prior authorization or precertification? You or the provider may need to call in advance of starting sessions to obtain approval.

6.    How many sessions will be covered? Do they need to be completed within a certain time frame? (i.e. 60 consecutive days, within 6 months,  calendar year, etc.)

7.    Do I have a deductible or co-pay?

8.    Is there coverage if I use a provider who is out of network?

9.    What type of documentation will you need (reports, progress notes)?

10.  If I exceed the alotted number of sessions, but therapy is still required, can I apply for more sessions to be covered?

Whenever possible, try to get something in writing, and keep track of the specific person you speak to. Even if coverage is denied, there is always a possibility of appealing your claim. Your physician and your speech language pathologist may be able to write a letter or provide documentation to support your claim.

Adrienne Frohlich is a licensed bilingual speech-language pathologist. She has extenisve experience with children and works privately with clients in the New York City area.  Adrienne is also an entrepreneur, check out the nurse purse at www.nursepurse.com  To read more about Adrienne, check out her full profile. 

To read more about Adrienne, check out her full profile

16 April 2013 15:41
by Adrienne Frohlich, M.S., CCC-SLP