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.
FIRST
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.
SECOND
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.
THIRD
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."
NEXT
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.
THEN
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.
INSURANCE AND IN-HOME ABA SERVICES
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.
GETTING YOUR HEALTH PLAN TO PAY
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.
