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Insurance Coverage

You may have a health care plan that includes coverage for psychological assessments, therapy, Applied Behavior Analysis, and behavioral evaluations. Although we are allowed to participate in some insurance programs at Reinforcement Unlimited, LLC, we are also more than happy to assist you with the process of out-of-network reimbursement for our services by filling out the appropriate 1500 form for you to submit for reimbursement.  Our advice is offered as a service and not meant to be definitive regarding your insurance or coverage.  Your best source of information is your benefits manager or insurance specialist at either your employer or the insurance company itself.

You must understand that your health coverage for Mental Health, also often referred to euphemistically as "Behavioral Health", is mostly likely NOT the same as your Medical or Major Medical coverage under your policy.  What this means is that what you are familiar with having paid, percentage and amounts, for your typical medical appointments is not necessarily a good predictor of what, if anything, will be covered under your Mental Health policy.  Your deductibles may be separate, different, or even with different companies.

It is possible to have Major Medical health insurance and NOT have a Mental Health portion of the policy.  This means, for example, that you can have a valid Blue Cross & Blue Shield of Georgia PPO plan in force, a valid card, have used the policy repeatedly at your pediatrician's, your GP's, or your OB/Gyn's offices and still not have coverage for Mental Health at all under your existing policy.  It is also possible to have Major Medical with one company, for example BC&BS of GA, and to have had that company sub-contract the Mental Health services under your policy to a third company, for example Cigna Behavioral Health.  When this happens it has always been our experience that the insurance card fails to make this clear, thereby misleading everyone into thinking that your coverage is with the named party on your card.  These are reasons that it is important to know your plan or seek advice from your HR department or the insurer directly.

It is important to know your coverage.  Look for coverage of all health related services under the major medical section of a traditional health insurance policy, or review the benefits booklet provided by your preferred provided organization (PPO), health maintenance organization (HMO), or self- insured employer. Your employee benefits manager is usually an excellent source of information about your health care coverage.  There may not be a specific reference to Applied Behavior Analysis (ABA)  and psychological services.  Look for terms such as "mental health," "psychological," or "behavior."  Applied Behavior Analysis (ABA) may also be included in references to "rehabilitation services," or "other medically necessary services or therapies."

Check for coverage limits and exclusions. Check to see if both evaluation and therapy services are covered.  If possible, get clarification of your coverage in writing.

Contact your insurance provider and ask for approval for services by Robert W. Montgomery, Ph.D. for the following CPT Coded services:

IF YOU ARE SEEKING AN EVALUAITON THEN ONLY TWO CODES ARE AVAILABLE - if you get an authorization that says "therapy" or any variation you need to know that you do NOT have an authorization for an Evaluation.  We routinely have parents specifically request authorization for testing/evaluation and receive authorization from the insurer for therapy.  This is NOT the same thing at all and if we proceed with the evaluation it will NOT be covered under the therapy authorization you were mistakenly provided by the insurer.

Evaluation =     90801 - Initial Diagnostic Interview (Limited to 1 hour)
                            96101 - Psychological Testing by the Dr. (Multiple Hours, includes direct testing, scoring, report writing, and review with patient/parents)

Individual Treatment =     90806 - Units of 1 hour of Therapy

Family Therapy =     90846 for Parents only - Units of 1 hour of Therapy
                                 90847 for Parents + Child - Units of 1 hour of Therapy

PLEASE NOTE - Regardless of what the clerk at your insurance provider says you can ask for authorization - our office is not required to do so.  It is typically much faster if you make the request (most contracts with providers allow the insurance company up to 21 days to make a determination if the provider calls but far less time if the insured person or their parent calls).  

VERY IMPORTANT NOTE:  Therapy is approved on a per visit basis because it is limited to 1 hour per week typically.  However, Evaluations are multiple hours on the same day over several days.  Frequently, the insurance providers will mistakenly approve parents for THERAPY (which typically reads on the approval form as "X Sessions between X/XX/XXXX and Y/YY/YYYY) this is NOT an approval for an evaluation regardless of what you may have requested over the phone.  You MUST have approval for an Evaluation using the CPT codes above prior to beginning the evaluation process in order for your insurance to be responsible for the services.  Such an approval must be in writing and we require a copy of any approval be on file prior to service delivery.  Any approvals may be faxed to us at 800-218-8249.  We will be happy to review any approval letters and help interpret them.

We are unaware of any major insurance carrier in Georgia, other than the Active Duty Military's ECHO program for TriCare and a special program under United Healthcare, that will reimburse for In-Home ABA services.  However, we are always open to learning about new policies or changes in existing practices by insurers. 
Attached is our check sheet for investigating whether your insurance policy may cover In-Home ABA services.

We are allowed to participate in certain insurance plans at Reinforcement Unlimited, LLC, however you are financially responsible for services rendered at Reinforcement Unlimited, LLC.  Even if we are not covered by your plan or are not a participating professional under your plan, we may be able to help assist you in receiving reimbursement for services rendered that are covered under your policy.  If your insurance company denies coverage for services, you should appeal the decision if the plan indicated that the service was covered.  Let us know that you have been denied and we will provide any documentation we have to support your claim.

You may always elect not to access your insurance coverage.  You must notify us prior to or at the time of service that you are planning to use an insurance carrier to pay for your services.  Once you have elected to pay out-of-pocket we are not obligated to bill your insurer or reimburse you any difference between what you insurer would have paid and what you have paid for the services rendered.  If you elect to access your insurance to help pay for your services you need to know that the insurance company has a right to access to your file and all information from us related to the services for which you are seeking reimbursement.


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