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How can I find out if my insurance will actually pay for therapy?

There are many plans that say that a child has speech therapy benefits but then turn around and deny therapy as ‘not medically necessary’. Of course we will not know for sure if your plan covers until we bill it and the Explanation of Benefits (EOB) comes back a couple of weeks after we see your child. To have a better idea if it will be covered, however, you can call your insurance and fill out this form. You will need to know the diagnosis/diagnosis code that we will bill for therapy. The therapist will give you this ICD-10 code at the evaluation or if you received an evaluation elsewhere the code should be on the paperwork you received.

Insurance Benefits and Eligibility form

Please download and complete the Insurance Benefits and Eligibility form. Contact your insurance company to get the information needed to complete the form. Return the completed form to PediaSpeech Services. Contact us if you have any questions.

In-Network Insurances

We accept all insurances, but are in-network providers only for the following companies (benefits are usually different for out-of-network coverage or may not even exist):

  • CIGNA (speech services only)
  • MEDICAID, but NOT any MEDICAID CMOs (such as Amerigroup, Peachstate or Wellcare)

Insurance Coverage

At times, dealing with insurance companies can be a hassle.  Always keep a record of all correspondence and telephone calls, including date, time, and name of person you speak with.

Prior to your first appointment it is imperative that you contact your insurance company to determine your child’ speech benefits. Insurance coverage DOES NOT guarantee speech therapy benefits. Those benefits are plan-specific.

Most insurance companies will cover the initial speech and language evaluation. However, to verify speech therapy visits we recommend you follow these steps:

  • Contact your insurance company and ask if they cover speech therapy.
    While most insurance plans do cover "speech therapy", they typically do so only in the case of "speech disorders that are due to an accident, injury, or illness". Most plans specifically exclude anything that they consider to be "experimental or educational" and not "restorative", or related to “developmental delays”. Speak to your child’s pediatrician to determine the most appropriate diagnosis for your child’s difficulties.
  • Your insurance company may ask you what treatment/procedure codes will be billed by our therapists.
    The most common procedural codes that our therapists will use to bill are: 92506 = Speech Evaluation and 92507 = Speech Therapy.
  • If they do cover it, is there a limitation on visits per calendar or contract year? When you have a limitation on visits it is your responsibility to keep track of how many you have had for the year.
  • Do you need a referral from your primary care (PCP) or pediatrician?
    Do you need a pre-authorization or pre-certification?  If so make sure that your physician calls it in (tel. 770-209-9826 ext. 100), or fax it to us (770-209-9876) before your first appointment with us.You MUST get a prescription from the referring physician for the evaluation and treatment of speech for your child. The physician can fax it to us at the fax number listed above, or send it to 4028 Holcomb Bridge Rd, Suite 202, Peachtree Corners, GA 30092, or you can bring it in with you on the first visit. We cannot treat anyone without a prescription. This is required to document medical necessity in case your insurance company requests treatment records. The referral prescription is unrelated to any referrals or pre-authorizations that may be required by your plan.
  • Do not hesitate to contact us if you need our assistance to determine if your particular plan includes speech benefits for your child.

Our financial contract is with you, not your insurance company.

We bill your insurance our current fees and accept their allowable amounts as payment only if we are their in-network provider (see the list above). We do require payment for services rendered at the time of service. This means that any copays or co-insurance that you are responsible for will be collected at the time of your visit.  If you have an annual deductible that has not been met yet, this too will be collected at the time of service.

Our office will work with you and your family in every way possible to locate funding sources for therapy.

However, you need to be aware that we CANNOT TAKE ANY RESPONSIBILITY for the DECISIONS made by YOUR INSURANCE COMPANY.

You are ultimately responsible for payment of therapy services rendered should all other sources default.

Should you have any further insurance-related questions, please call our billing department at tel. 770-209-9826, Ext. 5.

See also: Information and forms for new patients