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For my clients with Cigna and Anthem Blue Cross (no HMO medicaid plans such as Healthkeepers), I submit claims directly to the insurance provider.  This is because I have a contract with these insurance providers, which means I'm In-Network with those providers.  My In-Network clients are only responsible for their co-payments or co-insurance, depending on the terms of a client's insurance plan.  I provide evaluations and treatment plans to Cigna and Anthem when required, to document the need for care.  Although a client's plan might show a certain number of authorized OT visits, the insurance providers do assess a client's individual needs, and clients are not necessarily guaranteed the full number of visits authorized by their plan.   Anthem is good about honoring the terms of the policy, but Cigna requires a medical necessity review after five visits for all clients (which I submit), and Cigna often authorizes a set number of authorized OT sessions that at times might fall below the plan limits. 

I do not have contracts with other insurance providers, meaning I'm Out-of-Network with all providers besides Anthem BCBS and Cigna.  For my Out-of-Network clients, I collect the full payment for services rendered ($300 evaluation and $135 hourly therapy sessions), and provide clients with an invoice for payment that lists the appropriate treatment codes for OT.  My Out-of-Network clients are responsible for negotiating reimbursement and submitting all paperwork to their insurance provider.  If a client intends to seek reimbursement for OT services, it's important to verify your plan has out-of-network benefits, and ensure pediatric OT services are included with your plan.  If a client seeks a pre-authorization to guarantee reimbursement, the OT codes for evaluations are 97165, 97166 and 97167.  The OT codes for treatment sessions is 97530 - Therapeutic Activities.  The pre-authorization must show the correct codes to ensure client reimbursement.  OT services are billed by 15-minute increments, and hour-long sessions are four billing units.  If a client is pre-authorized for OT services, it's important to ensure the number of approved sessions is not confused with the number of approved billing units.  Ensure the pre-authorization specifies "visits" or the equivalent of one hour.  For example, 20 billing units would equate to five sessions. 

As I do for my In-Network clients, my Out-of-Network clients are often personally required to submit OT evaluations and treatment plans to their insurance provider, to demonstrate the services are medically necessary.  I provide all clients with the paperwork they need, and it's the Out-of-Network client's responsibility to submit any and all paperwork their insurance providers require for reimbursement.  Some providers such as Aetna do not often authorize Out-of-Network benefits, but will sometimes authorize a client for In-Network benefits with an Out-of-Network provider.  That does not mean I'm In-Network, a participating provider, or that I negotiate my rates, but it means a client can utilize their In-Network benefits for a specific service that would not typically be authorized by a client's Out-of-Network benefits.  That said, insurance providers such as Aetna and United Healthcare strive to reduce their costs by only utilizing In-Network providers, and will often drag out the process of reimbursement if clients are not thoroughly prepared.  It's for that reason I provide my clients up front the information they need to ensure effective communication with insurance representatives, and I hope this information arms my Out-of-Network clients with the tools they need to receive the most reimbursement possible.  And, I hope to manage client expectations to ensure I fairly devote my time to child treatment while parents handle details surrounding their own reimbursement.  Most clients understand I handle all my own billing, and can't be responsible for correspondence with Out-of-Network providers.  I appreciate everyone's patience with the process.

Ultimately, OT is a healthy investment in your child's short and long-term success, to ensure your child reaches their full potential.

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