1. Question: My insurance denied coverage for my child’s speech therapy. My child has a history of ear infections and had tubes for several years. What can I do?
Answer: If your plan specifies it covers speech therapy for conditions including illness, then your child’s history should make the therapy covered. Check the Medical Policy of your insurance plan and find the language that specifies when speech therapy is covered and when it is excluded. Then look at the language of the letter you received that states the coverage is denied. Write your appeal based on stating that the reason for the denial contradicts what is written in your plan. When you send your appeal letter, also include a letter from the child’s physician supporting the medical condition you are citing.
2. Question: I sent an appeal to my insurance company and they upheld the denial. Should I give up?
Answer: NO! You are entitled to 3 levels of appeal. Make sure when you send in your second level of appeal you include a letter of medical necessity from your physician, a letter or report from the speech language pathologist, and any other medical information you have that supports why you believe the therapy should be covered. When you send in any appeal, make sure you include the name of the patient, his/her date of birth, the specific documents you are including and why, and quote from the medical policy and the denial letter. Keep excellent records and copies of everything you send, and when you sent it. It is best to send your appeals via certified mail. If your plan is a standard NJ plan (not self-funded, or written out of state), you should also copy your appeal to the Department of Banking and Insurance.
3. Question: When I call my insurance company they tell me one thing, and you tell me something else. I feel like someone is not telling me the truth!
Answer: We are as frustrated by the games played by insurance companies as you are! Most of the time, the people we speak to at the insurance company are minimally trained clerks who are reading from a screen. They are not fully knowledgeable about the details of all of the insurance plans with their differing riders. Thus, it is very important for you to keep careful records of each communication you have with the insurance company. When speaking to the insurance representative, write down the date and time of the call. Ask for the name of the representative, and always get a reference number for the conversation as this provides evidence of the information you received during the call. You must do this each and every time you call your insurance company.
4. Question: I received a Pre-determination that said therapy would be covered, but then when you submitted the claim my insurance didn’t pay. Now what do I do?
Answer: The pre-determination is not a guarantee of payment or coverage. However, it is a strong basis for appeal. Use the information in response #1 and 2 above to construct your appeal.
5. Question: My insurance changed what should I do?
Answer: Make sure you provide us with your new insurance information immediately. Since all plans are different, what was covered by your old plan may not be covered by the new one. Also, maybe your old plan did not cover therapy, but your new one will.
6. Question: My company is changing insurance plans and is offering me a choice. How do I figure out which plan to go with to make sure my insurance will cover speech therapy?
Answer: Call us! We can help you review the options and guide you to the plan that is the most therapy friendly.