Insurance Reimbursement for “out-of-network” services (Overview) 


See below for Insurance Reimbursement for “out-of-network” services (Details, Step-by-Step)

Schneider Speech is “out-of-network”.

Our clients pay privately (cash, check or credit card).

 

This means:

  1. We do not participate in your insurance plan

  2. We do not submit claims to your insurance plan

  3. We do not receive payment from insurance plan 

 

Good news.

Even though we are “out-of-network,” there is a process called “Insurance reimbursement.”  It means: you may get money-back from your insurance company.  The process goes like this:

  1. You pay the fee for service

  2. You send claim to your insurance

  3. Insurance sends you check to reimburse you for out-of-pocket fees you paid. So, this can be a very valuable way to help you fund your work with Schneider Speech.  


 

 

Know your rights. 

Click here for Health Insurance Consumer Rights in New York State

 

  1. Health plans must give you important information about your coverage.

  2. Health plans must make sure you can get the health care services you need (access to care).

  3. Health plans must have a grievance and utilization review process in place for you to appeal coverage denials.

 

IMPORTANT: If the insurance company “rejects your claim” that is not the final decision.  (See above #3.)

First, you can pursue internal appeal to get the insurance to approve the services. 

Second, you are not alone.  Every state has an agency that oversees insurance companies  
You can include and involve the state insurance department, which oversees the insurance company. 

You can mention and “cc” this agency (“state insurance department”) in your correspondence with your insurance company.

TIP: We have found that the insurance companies are more likely to respond positively and quicker when the state agency is mentioned in your correspondence.

If you exhaust the process with your insurance company, then contact your state insurance department directly (See below.)

 

If your insurance provider is not providing information, submit a complaint to the state insurance department which oversees the insurance companies (“state insurance board”).
(If you’re outside New York State, search online for your local government agency.)

 

In New York State:

Click here for phone, email and online complaint in New York State.  

 

Address: NYS Department of Health, Office of Health Insurance Programs, Bureau of Consumer Services - Complaint Unit, Corning Tower - OCP Room 1609, Albany, New York 12237

Phone: 1-800-206-8125

E-mail managedcarecomplaint@health.ny.gov

 

 


Insurance Reimbursement for “out-of-network” services (Details, Step-by-Step)

 

 

In this article, we are going to walk you through the process of reimbursement, step-by-step. . We’ve also included some helpful tips.

 

We have found that many clients do receive reimbursement.  Sometimes quicker and easier, and sometimes with great persistence.

It’s up to you.

As a private practice, we will provide you with necessary documentation, but we do not file claims or work with your insurance company.

 

 

STAGE 1 - Before your appointment

BEFORE your first appointment, contact your insurance company (or the representative). 

  1. Request a copy of your policy (in writing) as well as any forms you need, to submit claims to your insurance company.

  2. Find-out your eligibility for “out of network” benefits.

  3. Ask about the process to receive “reimbursement” for “out of network” services.

  4. Make sure to explain the scenario:

    1. Tell them the context:
      You are interested in scheduling an appointment with a speech therapist, and you want/need to see an “out-of-network” provider.  

    2. Tell them about the payment arrangement:
      You will be paying out-of-pocket fees directly to the provider at the time of service.  You are calling to find-out about and set-up process to receive direct reimbursement from the insurance company.  This reimbursement should be send payable to you directly.  The out-of-network provider does not accept insurance or any third-party payment, and reimbursement should not be sent to provider.

    3. Tell them the reason why:
      You are going to see a provider “out-of-network” because you need a specialist.  
      (Depending on your specifics, maybe you were referred to see a specialist; or you may have contacted the local in-network providers and none of them have the competence/availability to provide the care you need.

  5. If the insurance company asks for our information or coding, click here for our information, address, codes and more.

  6. * Ask if you are required to obtain precertification (otherwise called “preauthorization”)

    1. Make sure to find-out if your insurance requires precertification, prior to you first appointment.
      (Many health insurance plans (but not all) require precertification to approve coverage.)

      In these cases, you need to file some paperwork, prior to beginning services to approve coverage; even if the diagnosis code (ICD) and treatment code (CPT) are approved as per the contract.

      Ask you insurance for details.  

      Typically, they may include the following paperwork to be filed:

 

  1. A prescription/referral from your medical doctor (i.e. pediatrician, ENT or general practitioner),
    This should include specific referral for therapy (speech therapy or voice therapy) as well as appropriate diagnosis (i.e. stuttering, voice, receptive-expressive language, etc.)

  2. Diagnosis and treatment codes, as well as additional information about the provider of services.
    Click here for codes and provider details 

After filing the paperwork, your insurance will give you a precertification number and tell you how many visits have been approved.  
Save this precertification number for your records.  
You MUST include this precertification number on all claim forms.

 

Sometimes they will give you two precertification numbers:
The first precertification number that is a one-time approval for your first evaluation appointment, and then a second precertification number applies to the subsequent treatment appointments.

 

It can be cumbersome to set-up the insurance and precertification number, but once you have it set-up, it's smooth sailing. (Just remember to track how many visits you have left and when they expire.)



 

STAGE 2 - Following your appointment

 

Following you appointment you will prepare and send a claim to your insurance.  This consists of two things.

  1. Insurance claim form - as your insurance for this form

  2. “Superbill” (paid invoice with all coding and information to satisfy insurance claim process).  
    For your convenience, you receive an email with superbill after every appointment.  You also have self-help access to the full history of your superbills. 

 

As your insurance for the claim form.

We will received a “super bill” (paid invoice) with all the medical coding, our information and record of payment.  You can attach this superbill to your insurance claim form, to send the claim to your insurance.  Some people do this after every appointment while others bundle several together, and send a claim for several appointments at once.  (Click http://bit.ly/AccessInvoices to learn how to access your Schneider Speech Invoices.) 

We recommend the latter, to save time and effort.  But it’s up to you.

 

Tips for filling-in your claims form

(See samples attached)

 

TIP #1 - Fill in the claims form for yourself.  (See specific fields itemized below and sample attached.)

  • Print your superbill/s, and attach them to the claims form to send together to insurance.

  • Use the information found on the superbill, to fill-in your claims form.

  • If you need Schneider Speech to sign the claims form, bring the form into your appointment and ask therapist to sign the claims form. 

 

Box 17-17 b: The referring medical physician (name and NPI)

 

Box 21: diagnosis codes (found on your superbill / paid invoice)

 

Box 22: n/a

 

Box 23: precertification number (provided to you by insurance)

 

Box 24: basic superbill info (date, place, type of service, etc. all included on your superbill / paid invoice)

 

Box 25+: practice billing information (i.e. all Schneider Speech information can be found on your superbill / paid invoice.