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.