Finding Out If Speech/Occupational Therapy Is Covered By Insurance
These general guidelines are intended to help you to find out if your insurance company will cover speech/occupational therapy. Again, please note these are general guidelines and there is no guarantee that speech/occupational therapy will be covered by your insurance company.
When speaking to insurance representatives, it is a good idea to take detailed notes, get full names of who you spoke to, dates of conversations, and numbers/extensions to call back should you have any problems or additional questions. You may wish to start a file folder specifically for these issues.
When calling your insurance company to determine if private speech/occupational therapy is a covered benefit, they may request some or all of the following information:
- Your name, member ID, policy number and other identifying information
- Inform them that we are a freestanding, private therapy clinic (not a hospital)
- All of our therapists are certified and licensed
- Procedure (CPT) and diagnostic codes (ICD-9)
Procedure (CPT) Codes
- Initial Speech & Language Evaluation – 92506
- Individual Speech Therapy – 92507
- Individual Cognitive Therapy – 97532
- Initial Occupational Therapy Evaluation – 97003
- Individual Occupational Therapy- There are several possible codes; two that most often apply are 97110 and 97112. Other possibilities include 97530, 97532 and 97533.
Diagnostic Codes- ICD-9
In some cases, the insurance company may ask for diagnostic codes. If your child has not yet been seen at our facility, explain to the insurance representative that we are unable to assign a diagnostic code without evaluating the child first. If necessary, our office can provide you with a list of possible diagnostic codes.
At the close of your conversation, ask for the approval or reasons for rejection in writing. Again, be certain to get the full name of the person you spoke to, with detailed notes.
Other general questions you may wish to ask:
- Under what circumstances is speech/occupational therapy covered?
- What are the restrictions (age, number of visits, percentage of reimbursement, etc.), if any?
General Insurance Tips
- Keep all correspondence from your insurance company together in one file, along with letters of support, and other documentation.
- Always document your phone calls to the insurance company, noting the first and last name of the person you spoke to, the date, and what you discussed.
- Keep copies of any letters, documentation, or anything that you send them. Insurance companies occasionally misplace information, and you don’t want to be left without a copy of your own.
- If you call in advance to try and determine if speech/occupational therapy is a covered benefit and you get a yes response, be certain to get the name of the authorizing person.
- If your claim is denied, find out exactly why the claim was denied (ask for the denial in writing, with specifics).
- If your claim(s) is denied on the basis of “not medically necessary,” find out exactly what criteria proves medical necessity, and who is qualified to determine this.
- If you gather any other helpful tips along the way, please let us know so we can share them with all of our families!
We are contracted with the following insurers: