1. Provide the representative with the insured’s name and policy number.
2. Specify that you want to get information on speech-language therapy for a child.
Provide your child’s age.
3. Do we have coverage for speech-language therapy for children?
4. Do we need to get a referral from the pediatrician (M.D.) before seeing a speech therapist?
5. Do we need to get pre-certification from the insurance company before starting speech therapy? How to we obtain pre-certification?
6. What are the speech therapy benefits? (write down as much information as you can, word-for-word)
7. Are there any conditions or diagnoses that are explicitly excluded? (If your child has a global diagnosis such as autism, Down Syndrome, or cerebral palsy, you may want to specifically ask whether that diagnosis is excluded.)
8. Is a speech-language evaluation required prior to starting therapy? Does it need to include standardized testing?
9. What is the deductible on my plan?
10. How much of that deductible is still left for this year?
11. What is the reimbursement rate for a non-network (out-of-network) provider?
12. Is there a maximum covered cost per speech therapy session?
13. Is there a maximum number of sessions per year that will be covered?
14. Is there a maximum dollar amount that will be covered per year?
Your insurance policy may have terms that say they will not cover speech-language therapy in children …
… if the area of difficulty is considered
‘developmental’
–
the insurance company assumes the child will outgrow it (but this is NOT necessarily true; the term ‘developmental’ is sometimes used for any difficulty that begins in childhood)
… if the area of difficulty is considered
‘educational’
in nature – the insurance company assumes the school district will take care of it at school (but many children who need services do not qualify for services through the school district)
… unless the treatment is
‘restorative’
in nature – this means the child has to have already gained the skill and then lost it (for example, due to a head injury
… unless the treatment is
‘medically necessary’
– this is an ambiguous term and each insurance company has their own definition. If your insurance company uses this term, ask for the definition and what information is needed to prove medical necessity.
Click here to see information on insurance appeals.
