How to Start Working with Your Insurance Company

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What NOT to do is just as important, maybe more, than what to do.

“Autism is UNTREATABLE”

Many parents have told us that their insurance companies view autism as untreatable. They consider autism as untreatable so they don’t have to cover anything related to it.

Almost any treatment billed to the insurance company with a diagnosis (ICD9) code of 299.0, 299.1, 299.8 or 299.9 will either be denied or limited by insurance plans.  Therefore it is CRUCIAL that you submit bills that charge for the symptoms you are actually treating, not autism. For example, the AAP admits that approximately 70% of ASD kids have gastrointestinal disorders but you cannot submit a bill to the insurance company for treatment of Gastroenteritis (ICD9 558) under ICD9 code 299, autism. You must submit it under 558. This guide is built on that principal – bill for the symptoms you are actually treating.

Bottom Line: Treating co-morbid illnesses/issues that often “come with” autism is extremely important. Do not trust when medical symptoms of a treatable issue are explained as autism. Seek medical assistance for each child’s unique needs.

 

What To Do Before You Start

Call your insurance company or talk to the benefits/HR department at your company.

You will need the following from them:

  • Contact information (website, address, phone and fax numbers, appeals department phone number and fax number) for your insurance company.
  • Policy and group number
  • Written copy of your insurance plan
  • Whether your insurance is self-funded or fully-funded (ERISA) and in WHAT STATE.  If self-funded, get the contact information and amounts for their “STOP LOSS” plan.
  • Is your plan a PPO, HMO, or POS?
  • What is the in-network co-pay?
  • What is the out-of-network co-pay?
  • What is the percentage of reimbursement for in- and out-of-network providers?
  • What are your individual and family in-network deductibles?
  • What are your individual and family out-of-network deductibles?
  • What is your out-of-pocket limit?
  • After you reach your deductable and limits, what percent is the reimbursement for out-of-network providers?
  • What is the lifetime cap?  What is the yearly limit?
  • Do you have home health care benefits? What are they? What are the limits?
  • Is pre-authorization, or pre-determination, needed for out-of-network providers? If so, what is the submittal process?
  • Which services are mental health vs. medical? Is mental health coverage different? What are the deductibles and co-pays, visits, limits and caps for mental health?
  • How many visits are you allowed for each therapy? What is the appeal procedure if more is needed?

KEEP DETAILED RECORDS of each call – including date, time, person’s name, phone number and extension.