Insurance Tips — Accessing your insurance benefits

For medical insurance to pay for therapy services, they must be deemed a medical necessity. In the evaluation and treatment process, your occupational therapist will develop goals and treatment strategies to assist in the development of function and independence. Unfortunately, these are not always deemed to be “medically necessary” and therefore are not always covered by insurance. Although your occupational therapist can assist you in the process of securing insurance coverage for services, you are responsible for payment in full when services are rendered.

Verify your benefits.

  • Call the customer service number on your insurance card to verify your benefits for occupational therapy.

  • Ask what your coverage is (e.g., 100%, 80%, 70), and what your co-pay is.

  • Major insurance companies usually allow for evaluation and a specified number of visits.

  • Give them your child’s diagnosis. If your child has a medical diagnosis, use it (e.g., ADHD, F90.1 or AUTISM, F84.0). If your child does not have a medical diagnosis, you can use R27.8 NEUROMUSCULAR INCOORDINATION or any other diagnosis that may apply.

  • If they ask for the procedure codes, use 97167 OCCUPATIONAL THERAPY EVALUATION and 97530 OCCUPATIONAL THERAPY PER UNIT (1 unit = 15 minutes; 1 hour = 4 units)

  • Ask for a written confirmation, and get the name of the person who verified the coverage.

Ask for an out-of-network provider or ask that the provider you are choosing to be paid “as par” (sometimes referred to as “gap coverage”).

Most pediatric clinics, except for some clinics within a hospital setting, are not preferred providers (i.e., they are considered out of network). Most insurance companies reimburse minimally for out of network providers. You should be able to qualify for full benefits according to your plan if you obtain “pay as par” status for the occupational therapist you are choosing to provide services for your child.

Ask the insurance company for a list of preferred providers. You may need to call those providers and inquire if they have a pediatric specialty (most in-network providers are adult rehab specialists). If there is not a provider within a specified radius on their preferred provider list that specializes in pediatric occupational therapy, tell the insurance company that the providers on the list DO NOT HAVE THE SPECIALTY EQUAL OR SIMILAR TO THE OCCUPATIONAL THERAPIST YOU ARE CHOOSING, AND THIS IS WHAT YOUR DOCTOR RECOMMENDED.

They may ask for the EMPLOYER IDENTIFICATION NUMBER for the provider you are choosing. Bloom Pediatrics, Inc. EIN# 84-4194772

Ask to speak to a supervisor or be assigned a case management person since your request is complicated and you will need to speak to someone that you will be able to follow-up with on a regular basis during the course of your child’s therapy.

Ask for the correct address for processing claims. Try to get a contact person, a phone number, and a fax number.

Get a prescription from your doctor, preferably from your pediatrician, exactly as follows:

Pediatric occupational therapy evaluation and treatment for YOUR CHILD’S NAME
Diagnosis: R27.8 Neuromuscular Incoordination (or your child’s medical diagnosis code)
Treatment: 1-2 times per week for 60-minutes each for 6-month period

If your pediatrician is not familiar with pediatric occupational therapy, or requires additional information in order to write the prescription, your occupational therapist, based on the information obtained from you in the initial interview, can either speak with your doctor or write a letter explaining the need for the evaluation or treatment. An additional fee will be included on your invoice if you request a letter.

Request for additional therapy treatments

Once you are authorized for the evaluation and initial treatments, you will need to take steps to request additional treatment sessions. Usually, occupational therapy is recommended in 6-month periods. Once your evaluation is completed, a written report may be provided detailing the recommendations. You may send this to your insurance company along with the doctor’s prescription to formally request an extension of benefits for additional visits. It is important that you get the name of the person at the insurance company to follow- up on the requests so that any “stalling” techniques can be minimized. Tell them you will send the information and will call them in 3 days.

Your insurance company may request progress reports and/or letters of medical necessity. An additional fee will be included on your invoice if you request a report or letter. Re-evaluations are sometimes covered by your insurance company and billed as an evaluation. Be aware that letters and other documentation charges are usually not covered by insurance