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Insurance Coverage for Pediatric Therapy Services

Know What Your Insurance Covers

Many insurance plans cover speech and occupational therapy services but there may be certain conditions or limitations to coverage.

It is very important that you know what your plan will cover before your child begins therapy. Call your insurance company to find out what your plan will cover. If you have secondary health insurance (if another person in your household also has insurance), be sure to check coverage under that plan as well. Here are some questions to ask:

  • Does my plan provide coverage for speech or occupational therapy?
  • Does my plan provide coverage for speech or occupational therapy in a home setting?
  • How many visits are allowed under my insurance plan?
  • If my child needs several therapies such as OT, PT, and Speech, will the same number of visits be allowed for each?
  • Are there any exclusions or limitations to therapy coverage?
    • For example, some insurance plans will not cover services for children diagnosed with developmental delay
    • Some payers (Tricare, for example) require a new physician referral for therapy services every 12 months
    • Some payers (many Humana plans, for example) will cover an initial therapy evaluation but will not cover ongoing treatment services until they have reviewed the plan of care and authorized a number of visits
  • How much will I be expected to pay out of pocket? Examples of out of pocket costs include co-payments which are due at each visit for each therapy service, any unmet deductibles, and any co-insurance amounts.

You are responsible for payment of therapy services if your insurance plan denies coverage. Insurance companies can deny payment for services even after they have authorized visits if they do not think the services are medically necessary. A quote of benefits does not guarantee coverage. The decision to pay for services is made by the insurance company when the claim is received and is based upon the insured person’s eligibility on the date of service.

It is very important that you fully understand your coverage and its limitations. For example, if your plan limits the number of visits, keep track of the number of completed visits to avoid higher out of pocket costs.

Although you may schedule your child’s therapy prior to obtaining insurance authorization, you are responsible for payment if the sessions are not authorized.

If You Have a Therapy Benefit, But Coverage Is Denied

  • Call your insurance company to determine the reason for denial. Ask for a copy of the plan’s policy for speech or occupational therapy benefits and an explanation in writing. Write down who you spoke with, the date and time, and what was said for all telephone calls. Maintain all communication in a file.
  • Inform your employer’s Human Resource and/or Benefits director of the limitations in coverage. Ask if there are any options in coverage or if he/she could contact the insurance company on your behalf. Inform leaders in your organization of the coverage limitations and ask that coverage be included in future medical benefits.
  • Contact your child’s pediatrician and referring physician and ask that they write a letter to the insurance company in support of the need for therapy services. Your child’s speech or occupational therapist can also write a letter of medical necessity.
  • Make a formal appeal to your insurance company for reconsideration. Contact the Member Services department of your insurance company for the process for appealing insurance denials, the mailing address for the appeals department, and the expected length of time to receive a response. Many insurance companies require that an appeal be submitted within 30 days of receiving the initial denial of the claim.
  • Send all appeal documentation via certified mail and then follow up with a phone call.
  • Discuss options for scheduling, which could decrease the cost of care, with your child’s therapist. Options may include scheduling sessions less frequently while increasing exercise/activity programs at home.