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Advice for obtaining insurance coverage for kids with special needs

Melanie Fowler M.S., Special Education Educational Diagnostician Founder The Reach Academy of Fort Worth The Fowler 4 Group
Advice for obtaining insurance coverage for kids with special needs

The cost of raising a child with special needs can vary dramatically depending on the disability and severity. Many families turn to second mortgages, credit cards and raid their retirement funds to find the money wherever they can.

Can you get your health insurance to cover the costs of special needs therapy? The chances are better than you might think. The advice below may save you thousands of dollars a year and help you get the coverage your child needs.


Do

Do understand your insurance policy and what your plan provides

It is important to understand your insurance policy in order to know what is needed for coverage approval. What is the in-network copay or what is the out-of-network copay? What is the percentage of reimbursement for in- and out-out-network providers? What are your deductibles? What is your out-of-pocket limit? Is preauthorization or predetermination needed for out-of-network providers? If so, what is the submittal process? Knowing your plan will increase your chances of obtaining approval from your insurance company. And it also will save you time in the submittal process.

Do obtain a medical diagnosis

A crucial first step in obtaining coverage is to get a medical diagnosis. It may be necessary to obtain a letter from your doctor stating that the specific therapy is a medical necessity and that the disorder is neurologic, rather than developmental.

Be sure to read your insurance policy’s exclusions carefully and have doctors avoid such language in their letters or reports to the insurance company.

Do be persistent

It is very common to receive a denial of coverage from insurance companies. If you receive an initial denial, always appeal the decision. This can be a very time- consuming process, but persistence has been known to pay off.

Be sure to check the denial letter for any discrepancies between your child’s actual diagnosis and the one used to deny coverage. This can help with the process of appealing the decision.

Do take good notes and include all necessary information

In order to file an official appeal, you will need to get your ducks in a row. Necessary information includes your health insurance plan, a written denial, doctor and therapy bills, a doctor's referral and therapy prescriptions, medical records, a physician’s letter of medical necessity and study references that show the validity of the treatment or therapy.

Be sure to take good notes and get names, phone numbers and extensions when contacting your insurance company. Learn and follow the insurance company’s guidelines and processes--and use the proper forms. If you don’t follow the exact process, the claim will come back marked, “denied.”

Do be creative

It is vital to contact the insurance company to confirm the denial and get reasoning. Still getting nowhere? Be creative. You may need to try to submit bills that charge for the symptoms you are actually treating--and not the disorder.

Depending on the practice where your child is receiving care, you may be able to receive help in billing originally under the codes for the symptoms. You will need to discuss this with the practice to seek approval for symptomatic coding. 


Don't

Do not expect an approval right away

Your insurance company may deny coverage several times before finally approving your claim. Yes, it may take time. But it is possible to triumph with persistence and patience. Pay attention to the reason(s) for denial and do not be afraid to use strong (but professional) language stating why you and your child’s doctor disagree with the insurance company’s assessment.

Do not fail to appeal the decision

Do not be shy about challenging the decision with an appeal. If your policy states that a particular therapy should be covered, you will need to appeal in order to obtain coverage.

Do not wait for answers

After submitting your claim for coverage, do not wait for your insurance company to contact you. Make sure to follow up on the claim and take detailed notes, including full names of insurance representatives, dates of conversations and numbers/extensions to call them back should you have any problems or additional questions. 

Do not fail to reach out and ask for help

As with many things, one of your best tools is knowledge. While doing your own research, don’t be afraid to ask for the help of others. In fact, you will most likely need the help of your child’s physician and the practice where you child is receiving care to obtain approval of coverage. It never hurts to ask for help, and you will find that more people are willing to help than you think.

Do not forget to pay close attention to coverage criteria

Pay close attention to the criteria for coverage in your specific plan and use it to support your argument or appeal. You will need to specifically refute your insurance company’s reason for denial of claim. If you do not address the denial reasons, you will not win. Know your policy plan and be ready to back up your appeal by using documentation of physicians and therapists who work with your child.


Summary
Jumping cartoon

It is crucial to know and understand exactly what is needed in order to receive the coverage approval of the insurance company. Obtaining a medical diagnosis and involving your child’s physician and therapist/s are important steps in building a good argument or appeal for your case.

In speaking with your insurance provider, it is essential to keep a detailed record of notes, names, dates, numbers and any other specific information pertaining to your case.
Preparation and persistence are key to obtaining insurance coverage for special needs therapy.


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Melanie Fowler M.S., Special Education Educational Diagnostician Founder The Reach Academy of Fort Worth

Melanie Fowler earned a Bachelor’s degree in Speech Language Pathology from Louisiana State University and a Master’s degree in Special Education from Texas Woman’s University. During graduate school, she also completed her Educational Diagnosti...

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