Do you take insurance?
Oftentimes, the first question parents ask me is, “Do you take my insurance?” While this seems like such a simple question, the intricacies of insurance make the answer complicated.
A little information about insurance…
North Star is not in-network with any insurance companies, which makes us an out-of-network provider. Because of the complexities of insurance coverage, the difference in the price you pay between an in-network and an out-of-network provider varies based on your insurance plan. The first thing to look for is whether you have an HMO or a PPO insurance plan. PPO plans allow you to choose your providers. With an HMO plan, you can only see providers with pre-approval from your insurance company. While HMO plans don’t typically offer out-of-network benefits, PPO plans do. If you have an HMO, Medicaid, or Medicare plan, you likely are not eligible for out-of-network benefits. However, if your insurance card says PPO, POS, or out-of-network, then you may have out-of-network benefits.
In-network: Providers who are in-network sign a contract with each insurance company. When you get services from an in-network provider, you still have to pay your copay and meet your deductible. It really depends on your plan, but your copay may be close to the same price or more than paying out-of-pocket with an out-of-network provider. If you haven’t yet met your deductible, you pay for the full cost of therapy until your deductible is met, regardless of whether you get treatment from an in-network or an out-of-network provider. If you have no copay or a no-deductible or low-deductible plan you may end up paying more with an out-of-network provider.
Out-of-network: Providers who are out-of-network haven’t signed any agreements with insurance companies. However, with a PPO plan, you can often receive therapy from an out-of-network provider and get reimbursed by your insurance company. With out-of-network providers, you pay for therapy out-of-pocket and then submit the claim to your insurance company for reimbursement. You should confirm your out-of-network insurance benefits before your child starts therapy if you plan on seeking out-of-network reimbursement.
If your child is under three years old and your insurance doesn’t cover therapy, you have a high copay, or you have a high deductible, then your child may qualify for free therapy or copay assistance through the San Diego Regional Center.
The benefits of going out-of-network with North Star…
Choose where your child gets speech-language therapy. You deserve to be able to control who your child’s gets therapy from. When you stick to providers that are in-network with your insurance, you give up control over your choice of providers, limiting your options and your search to providers who have agreed to the contractual guidelines provided by your insurance company. For some insurance providers, you may have lots of options. Other times, you might only have one or two providers to choose from. By choosing an out-of-network provider, you can get back the control by hand-selecting your child’s provider based on your child’s needs and what is most important to you.
The most advanced training and up-to-date research-supported techniques. North Star’s neurodiversity-affirming speech-language therapists have advanced training has given them the tools to understand and apply research regarding treatment techniques that have the biggest impact on your chid’s skills. Oftentimes, therapists use outdated or trendy techniques that aren’t supported by research. At North Star, ask us why I’m doing what I’m doing and we can refer to the research that guides our treatment methodologies!
Help your child make faster progress by participating in parent coaching. Speaking of research… There is extensive research supporting parent coaching during speech-language therapy. Research suggests that parents who receive parent coaching tend to be less stressed; children whose parents receive coaching tend to make faster progress. If your child has received therapy in the past, you likely received parent education, which is distinct from parent coaching. Parent education usually involves the speech-language pathologist giving you a handout or strategy to practice at home. Parent coaching actually gives you the opportunity to practice the strategy during the appointment, so that you leave empowered with the tools to help your child improve their communication skills.
Ready to try out-of-network speech-language therapy with North Star?
Before your first appointment with North Star, call your insurance company to get information about your out-of-network benefits.
Call the member services phone number on the back of your insurance card. When you speak with an agent, let them know you want to know your coverage for speech-language therapy (also called speech therapy) with an out-of-network provider.
It is important to document the information you get during the call, as different agents may interpret your policy and coverage differently. Document…
Name of the agent and their ID number, if they have one
Date and time of the call
Reference number for the call
You will need to give them your child’s information, including their name, date of birth, insurance member ID, and policy/group number.
Ask the following questions:
What is my out-of-network coverage for speech-language therapy?
Do I need pre-authorization or pre-certification for speech-language therapy? If so, how do I obtain it?
Are the following CPT (procedure) codes allowed?
92523 Evaluation of speech and language
92507 Individual speech-language therapy
If your child uses a speech-generating AAC device: 92608 Therapeutic services for a speech-generating device
Are the following ICD-10 (diagnosis codes) allowed?
F80.0 Phonological disorder
F80.1 Expressive language disorder
F80.2 Mixed receptive-expressive language disorder
R48.2 Apraxia
R48.8 Other symbolic dysfunctions
If your child has a medical diagnosis, such as autism, ADHD, Down syndrome, or any other syndrome, ask about your child’s specific diagnosis. In this case, you may wish to contact North Star for guidance with codes prior to calling your insurance company.
Are there any exclusions?
What is your process for filing a claim for out-of-network reimbursement?
Where do I find any forms I may need?
What additional forms or paperwork do you need to process my claim?
How do I file my claim (e.g., online, mail, fax, etc.)?
Do I need to file my claim within a certain period of time after the date of service?
How long does it take to process my claim?
Can I appeal if my claim is denied?
What is the “allowed amount” for non-participating providers or out-of-network reimbursement?
Before your child’s first appointment, let us know that you want to use your out-of-network benefits for therapy and share information about your phone call with your insurance company, including any exclusions in coverage. We will do our best to interpret the information you received from your insurance company.
When you complete our intake paperwork, be sure to include your child’s insurance information so that we can include the member number on the documentation you will need to seek reimbursement.
Throughout the course of your child’s speech-language therapy at North Star, at the beginning of each month, you will receive an email with the “superbill” (itemized receipts for insurance) documents from the previous month to provide to your insurance company when you request out-of-network reimbursement. We can also provide you with a CMS-1500 form if required by your insurance company.
North Star cannot guarantee that you will be reimbursed, or that you will be reimbursed in full, but will work with you as needed to support you throughout the process.
