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June 3, 2020

How to Fight an Insurance Denial for Pediatric Therapy

If you have a child who struggles with physical, developmental, or behavioral conditions, then you know that regular therapy is essential

Most people need help paying for therapy, which is where health insurance comes in. Private insurance does cover pediatric therapy visits, including physical, occupational, speech, and ABA services for children on the autism spectrum. However, most plans also have limitations and conditions, which can lead to your insurance company denying a request for coverage or a claim.

Of course, it’s frustrating to receive a denial, but that doesn’t mean you should automatically give up. We present some practical ways you can launch an appeal and turn that “no” into a “yes.”

Rejection versus denial: Understand the difference

Sometimes a claim is rejected rather than denied. This usually happens because of incorrect information on the insurance form. Be sure to check with your insurance company or provider to find out why the form was rejected and fix the mistake. That might be enough to get an approval.

Reasons for claim denials

Before you can fight the edict from your insurance company, you need to understand why most claims are denied. This will help you determine a strategy to fight the decision.

Five common reasons for claim denials include:

  • Incomplete, incorrect or missing billing or coding information
  • Procedure/therapy is not covered under the plan
  • Plan coverage limits
  • Therapy/medication is not covered under the plan formulary
  • Out-of-network provider

How to fight a denial

Now that you know the main reasons why a coverage or claim might be denied let’s go over ways you can change that decision.

Step 1. Gather the facts

Before wading into a fight with your insurance company, be sure you are armed with information.

Keep accurate and thorough records of everything about your child’s therapy. This includes all communications from providers and the insurance company, dates and outcomes of therapy sessions, and recommendations from the provider.

  1. Go over your policy to determine what is covered and what is not.
  2. Understand the process of getting approvals. For instance, do you need to submit for approval before the visit?
  3. Understand how to make a written appeal and how long it will take before you get an answer.

It’s also a good idea to ask if there is someone at the insurance company who is trained to settle disputes. If they don’t have such a person or you can’t get a name, try reaching out to your State’s Insurance Department.

You may want to reach out to the Insurance Department anyway so you understand the laws in your state. For instance, some states have provisions that allow for appeals to be reviewed by an outside party if you have received continued denials.

Step 2: Write an appeal letter

After you have gathered the facts, it’s time to write an appeal letter to your insurance company. A written letter is a means of having your case examined. Before writing the letter, be sure you understand the reason for the denial.

Without this information, the insurance company will have a hard time reviewing the appeal.

There are three parts to include in an appeal letter:

  1. Opening statement. The reason why you’re writing, the service/treatment/claim that was denied, and why it was denied.
  2. Medical history. Explain your child’s medical history, including diagnoses, previous treatment/therapy, and why this treatment/therapy is medically necessary.
  3. Providers’ recommendations. Include documentation and recommendations from anyone who provides care for your child, including therapists, pediatricians, and specialists.

Be sure to send your appeal letter to the correct person within the specified timeframe. If you miss the legal window to file an appeal, your claim may be denied, no matter what.

What if your appeal is denied?

If your appeal is denied, you may still have options. Consider contacting an attorney or an advocate who specializes in fighting insurance denials.

As stated above, a good place to start is with your State Insurance Department. Every state has different laws, so there is no one-size-fits-all solution.

Other resources:

  • State Protection & Advocacy (P&A) organization. P&A organizations work at the state level to protect individuals with disabilities.
  • Legal Aid Clinic. This may be an option if you think the denial is in violation of state law. Just do a search for a Legal Aid Office near you.
  • State and/or federal lawmakers. – Find out who your local state representatives are and then let them know about your attempts to seek treatment for your child.

About Lumiere Children’s Therapy

Lumiere Children’s Therapy provides treatment and support to help your child improve and achieve traditional milestones. We will verify your insurance benefits before any service and will process insurance claims we can submit on your behalf.

We strive to create experiences that help forge connections between parents and children, while revealing the potential in each child, regardless of his/her skills.

Our services include:

  • Speech therapy
  • Occupational therapy
  • Developmental therapy
  • Physical therapy
  • Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (ASD)
  • Social work
  • Augmentative alternative communication
  • Early intervention
  • Teletherapy

If your child struggles with developmental delays, speech, or physical impairments, we can help. We will do our best to work with your insurance company and locate other sources of funding to provide the therapy your child needs.

Learn more about how our team of clinicians works to improve the lives of children and their families.

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Premier Child Therapy Services in Chicago, IL

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