Contacting the Insurance Company

When contacting our office we will advise you to contact your insurance company to verify the terms of your coverage for speech, language and/or feeding therapy as well as your expected out of pocket costs. Below is a script to follow when contacting your insurance company.

After providing your member ID and your or your child’s date of birth (DOB) to the customer service representative please ask the following questions. Take careful notes of the responses provided and mark down the date of your phone call.

  1. Are there any limits or exclusions to coverage for speech therapy CPT 92507 (and/or feeding therapy CPT 92526)?
  2. Is ICD-10 ____________ covered under my plan? (You will be given the relevant ICD-10 code by our office during the first phone call to the office.)
  3. In order to receive speech (and/or feeding) coverage are any of the following required:
    An electronic referral
    Prescription
    Predetermination
    Precertification
    Authorization or Pre-Authorization
  4. What is my out-of-pocket cost of therapy for an in-network provider? Do I have a copay and what is it? Do I have to pay a coinsurance fee and what is it? Do I have to pay a deductible and what is it?
  5. Do I have out of network coverage for speech (and/or feeding therapy)? What would my out-of-pocket costs be? Do I have a copay and what is it? Do I have to pay a coinsurance fee and what is it? Do I have to pay a deductible and what is it?
  6. Is there any other information that I need so that I am able to access my speech therapy benefits?
  7. Can you email, fax or mail to me the exact language pertaining to my coverage for speech therapy (and/or feeding therapy)?
  8. Is this phone call being recorded and can I receive a reference number to our conversation?

General Information About Speech and Language Therapy Coverage

Some things to look for when reviewing your health plan benefits booklet are:

  1. Terms such as "speech-language pathology," "speech pathology," "speech therapy,"
    • Coverage information for speech and hearing services may also be included under "physical therapy and other rehabilitation services" or "other medically necessary services or therapies."
    • Hearing services may be found under diagnostic services.
  2. Coverage of both assessment ("testing") and treatment ("therapy") services for hearing and speech disorders.
  3. Limitations and exclusions are typically located in a separate section often referred to as "Things We Don't Cover" or "Exclusions to Coverage".

Common limitations and exclusions include:

  1. No coverage for speech and/or hearing disorders that have a developmental or congenital cause.
  2. Coverage for acquired disorders only or only for treatment that is restorative or rehabilitative.
  3. No coverage for certain disorders, such as stuttering and autism.
  4. A limit on the dollar amount that will be reimbursed for speech and/or hearing services.
  5. A limit on the number of speech and/or hearing therapy sessions that will be reimbursed.
  6. Coverage may also be limited to certain settings such as a hospital or clinic.
  7. No coverage for devices such as hearing aids or speech-generating devices.

Your health plan may require that you obtain prior approval or that a physician "prescribe" speech or hearing services. This may also be referred to as "pre-authorization", "pre-certification" or "pre-determination". Read on to find out the subtle differences between these three terms.

  • Pre-authorization is how the health plan verifies your coverage against the proposed care.
  • Pre-certification requires that you notify the health plan before undergoing certain diagnostic or surgical procedures. The health plan assigns an authorization number.
  • Pre-determination is a health plan requirement in which the provider must request confirmation from the health plan that the service or procedure to be performed is covered under the policy.

Unfortunately, prior approval does not always guarantee coverage. Always check with your health plan before having any service performed.

Remember to keep copies of all documentation, including date, time and contact person!

Request that they provide any clarification of your coverage in writing.