Private Health Plans

Typically, a health benefit plan is a contract between your employer and a third party (an insurance company). These contracts vary widely depending on the benefits and coverage levels negotiated by your employer. Oftentimes, the benefits information provided by your health plan is confusing-leaving you unsure of what speech and/or hearing services will or won't be covered.

Remember, the benefits booklet you receive is merely a summary of benefits-not actual contract language. You may need to examine the policy or contract to truly understand your health plan's coverage and limitations. The policy or contract can be obtained from your benefits manager.

It is vital that you review the speech and hearing benefits information provided by your health plan and employer before you receive services.

Tips and strategies for ensuring that speech and hearing services are covered

Understand Your Benefits

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

Terms such as "speech-language pathology," "speech pathology," "speech therapy," "hearing care, "audiology,".
- 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.
Coverage of both assessment ("testing") and treatment ("therapy") services for hearing and speech disorders.
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:

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

When in doubt, check it out! If you are unsure about the coverage your health plan provides for speech or hearing services call the 800 number listed on your ID card and speak to a customer service representative. Request that they provide any clarification of your coverage in writing .

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

Get Permission Before Your Visit

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 your policy.

Every private health plan is different, so you'll need to call the 800 number listed on your ID card and speak to a customer service representative to determine what speech or hearing services need prior approval. 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!

Educational vs. Medical Issues

Children have access to speech and hearing services through the school system as well as through the medical system. Each system however, has specific policies.

School systems provide speech services only to children who qualify under a very rigid set of federal regulations and state education laws. Children who do qualify for speech services in the school system may be placed on a waiting list. Furthermore, speech-language pathologists, who provide speech services in the schools, typically have more children on their caseload than recommended. Supplemental therapy, from a provider outside of the school system, reduces the time children spend in treatment.

Only when families seek supplemental services from their health plan, do they discover that the majority of private health plans will not pay for services that may also be provided in a school setting. As a result, the child becomes the ping-pong ball that bounces between the school and medical systems- all the while not receiving needed services.

Communication disorders affect an individual's health and education simultaneously. Therefore, children are best served when providers (speech-language pathologists and audiologists) from both the school and medical systems work collaboratively to identify the best treatment setting for each child. Many times, children attain their best potential by being served in both settings simultaneously.

Submitting a Claim

Some speech-language pathologists and audiologists will file claims for services rendered, whereas others may request that the patient file the claim with their health plan.

If the speech-language pathologist or audiologist has signed an agreement with your health plan, they are required to file the claim. If not, they may provide you with the necessary information to be attached to the claim form. Most private health plans require specific codes for the diagnosis and treatment provided.

If you file the claim with your health plan:

Fill out the claim form provided by your health plan. Print legibly and be thorough!
Determine how quickly you need to file the claim. Some plans require claims to be submitted within a certain number of days. This information can be found in your summary of benefits.
Attach any required documentation such as a treatment plan or physician referral.
Keep copies of all documentation, including date, time, and contact person!

Appealing Denied Claims

Your health plan may deny reimbursement claims for a variety of reasons. But, you have the right to appeal your health plan's decision.

Don't procrastinate! Most states mandate the timeframe in which appeals must be processed. Once an appeal is filed, the health plan must also respond within a specified time period.

Preparing to Appeal

Know your health plan's claims appeals process before you begin. This will allow you to gather the information required by the health plan (e.g., documentation of services, health plan language).
Obtain the health plan's rationale for the denial in writing. This is commonly referred to as an Explanation of Benefits (EOB). The EOB will tell you why the health plan denied the claim.
Review the actual contract language NOT the benefits summary to determine if the service is listed as a benefit under your plan.
If the claim is being denied because the service is not a covered benefit:
- Review the actual contract language (See "Coverage" section above). Is the service listed as a benefit? If so, submit that page with your appeal letter.
- Ask your physician to prepare a letter in support of coverage.
If the claim is being denied because the service is not medically necessary:
- Determine if the service is a recognized treatment for your condition. For a service to be considered medically necessary, you will need to demonstrate that the service:
  - was or is being performed for a medical reason,
  - is usual and customary treatment for your condition; and
  - is ordered by a licensed physician (if required).
- Ask your physician to prepare a letter in support of coverage.

The Appeal Letter

Prepare an appeal letter that includes:

patient's name,
subscriber's name,
health plan identification number,
date of service; and
the reason why you are appealing the denial.

Request a review of the claim by a speech language pathologist for an appeal of speech services or an audiologist for an appeal of hearing services.

Gather the necessary supporting documentation (e.g., EOB, pertinent pages from your benefits booklet, treatment plan, test results, letters of support).

Address the appeal letter to the appropriate health plan representative. If you have not identified this person, call your health plan's customer service department and request the name and address of the person or department to which appeals should be addressed.

Send the appeal letter and supporting documentation via certified mail, return receipt requested. Be sure to keep the return receipt with the signature from the health plan representative.

After the Appeal

believe the claim is being denied unfairly,
have difficulty obtaining a copy of your policy; or
are not getting information in a timely manner.

To register a complaint, go to the National Association of Insurance Commissioners website. The Office of the Insurance Commissioner or State Insurance Department regulates insurance.

The insurance commissioner will contact your health plan if your complaint warrants investigation. Health plans take complaints to the state insurance department very seriously.

Follow up with the health plan representative regularly to check on the status of the appeal.
Keep copies of all documentation, including date, time, and contact person.
Continue to appeal claims denied by the health plan as it may take more than one appeal to reverse a health plan's denial.
Be patient! Be persistent! Don't give up!

The External Review Process

If the appeal is denied, you have exhausted the health plan's internal appeals process, and you still believe your treatment meets coverage definitions, consider taking the case to the external claim review level. Currently, 42 states have an external review process (go to the Kaiser Family Foundation's Consumer Guide to see each state's procedure and contact points).