Insurance company said ST was covered, but now they're denying claims. What do I do?

[cristeen]

I specifically checked with the insurance company the exact CPT codes the therapist was going to be billing under before we started ST.  They told me he was covered and claims would be paid.  I just got an email from the therapist that the claims for October and November have been repeatedly denied, and they're now my responsibility to pay.  If we had known it wouldn't be covered by insurance, I never would have done it, because EI would have covered it (they'll cover if insurance doesn't, but I have to use their therapists). 

What do I do now?  Other than paying the therapist, obviously.  How can I fight this? 

[Buzzer Beater]

Do you have your initial inquiries in writing?

What is the reason for denial?

We got some appliances approved in writing for dd2, and paid out of pocket. Then the bill was denied for out of network provider. Sometimes they approve the code but not the therapist.

[AbbyGrant]

Not sure if this is what's going on with your insurance company or relates to your child's issues, but my health insurance provider will cover ST but not in regard to developmental delays or autism.  Sadly, it's perfectly legal in my state and many others.  

[RiverTam]

With regard to the provider, call the office and make sure that they used the correct codes. You told them what codes to use, but that doesn't mean they did it. Be polite, even if they're cranky.  I've had a number of conversations with cranky billing offices, only to have the problem be their mistake, not mine or the insurance company's.

With regard to the insurance company, your "what to do now" is covered by your policy.  Every policy should have a process for denied claims when the insured doesn't agree with the denial. You need to go the insurance companies web site and find out how to file a written appeal. This usually has a limited time frame for filing appeals. For my company, we have 180 days to file a written appeal after a claim is denied.  The insurance company has a claims reconsideration form on its website with directions. If that process doesn't work, there should be at least one more level that you can appeal to. If that doesn't work, hire a lawyer.

Alternatively, you can seek services through early intervention or your school district.

If those aren't available, you can pay privately. If you can't afford private therapy, you can seek services through a university graduate student speech therapy clinic.