Insurance for Beginners
For those totally new to health insurance, here is a short primer to get you started.
Before you begin, you need to know who is responsible to pay for what services (Who Pays For What - PDF).
CPT (Code of Procedural Terminology)
CPT is the code used to describe what treatment is being provided (i.e., 92507 is “speech therapy).
ICD9 (International Statistical Classification of Diseases and Related Health Problems)
ICD9 is the code used to give the diagnosis (i.e. 299. is the ICD9 for autism), assigned by the doctor or therapist.
In-Network vs. Out-of-Network
If your doctor or therapist accepts your insurance and bills your insurance company directly with merely (maybe) a co-pay from you at your visit, they are an IN-NETWORK provider. If they don’t, then they are an OUT-OF-NETWORK provider.
Explanation of Benefits (EOB)
The EOB is a document sent to you every single time someone bills your insurance company for a treatment or visit. It tells you who is billing; for what service; on which date; cost of service, how much the insurance company paid, or didn’t; and if you owe the provider anything more after the insurance company paid their portion. Don’t throw these away, ever.
This is the paper that says what services were provided, when, to whom, by whom, and contains the appropriate billing (CPT) and diagnosis (ICD9) codes your insurance company will need to process payment. This is the receipt you leave the doctor’s office with at every visit. Usually these are only provided by physicians, and not by therapists. Therapists typically only provide a bill/invoices for their services. Here is an example of a superbill.
Rehabilitative vs. Habilitative
Insurance companies often will only pay for one or the other. Rehabilitative means to restore to its former use and habilitative means to teach a new skill. The purpose of this is that if you had a skill and lost it (i.e. regressed) then it’s more likely they will pay for it than if your child never had the skill to begin with.
What if I Don’t Have Any Insurance?
There are several options if you don’t have health insurance. First, if you qualify financially, you can get SSI and Medicaid in your state that will provide medical coverage for you and/or your children. Some states disregard your income when your child has a disability - Read the Medicaid section on page 22 for more details. If you don’t qualify for Medicaid, all states also have a Children’s Insurance Program which is an affordable option for most but, like an HMO, is limited in what it provides. There are also Health Savings Accounts (see page 19). This article is written for those with private health insurance only.
How to Bill Your Insurance Company for an Out-of-Network Provider
So, you go to a doctor that isn’t on your insurance plan and you pay (cash, check, credit, etc.) the provider directly and they give you a Superbill or invoice. Now, what do you do with it to get reimbursed?
Insurance companies always provide Out-of-Network provider reimbursement forms. If you didn’t receive any with your insurance booklets when you were hired, or have lost them, you can:
- Ask the company’s HR person to give you more
- Go to the health insurance website to print one out
- Call the insurance company and have them mail you some
Complete the insurance company’s reimbursement form(s) and attach the superbill or invoice. It’s also a very good idea to make sure your superbill shows that you already paid the provider (shows a zero balance). Then send a cover letter saying you already paid for the service and reimbursement should be made out to you, and sent to you directly. Attach any pre-authorizations or prescriptions for the service and a letter of medical necessity if you have them.
NEVER SEND ORIGINALS, ONLY PHOTOCOPIES. Parents often report back that their insurance company “lost” their submittals, again.
There is more than one way to skin a cat…
TIP! Check your insurance plan for HOME HEALTH CARE coverage and exactly what it can cover. Some plans cover ABA or other therapies in-home in addition to, or instead of, in the office. You might qualify for 90 in-office visits and 90 in-home visits without a fight!
What is a Certificate of Coverage?
The Certificate of Coverage describes the Benefit Options and other features under the Plan in great detail.
Here is a good example of a Certificate of Coverage
You can obtain this through your company’s HR department, the insurance company itself (usually on their website) or ask them directly.
The Summary Plan Description is only an overview and may even conflict with the Certificate of Coverage so you will need to review the actual Certificate of Coverage handbook.