How to get claims for your child’s treatment approved and paid

You’ll do anything to get your child the therapies and treatment they need, and you assume everyone involved in your child’s care is on the same page. Then a denial arrives in the mail, leaving you frustrated, angry and facing an astronomical bill.

So we turned to a few experts with insider tips on how to help turn that “No” into “Yes”—Yoland LeLuna, client account coordinator, Sharon Kucik, family service coordinator, and Cara Long, parent liaison, at Easter Seals DuPage& Fox Valley.

  1. Call your insurance company directly and ask for details about your plan benefits before starting therapy.
  2. Find out if your providers are in network with your insurance plan using the provider tax ID ahead of time.
  3. Verify that the diagnosis code (this will be included on the prescription given to you by your doctor) and billing codes (you can usually get this from the provider that will be rendering you the service) are valid and billable by calling your insurance provider. In general, when trying to get therapy services covered, you will be more successful using a diagnosis code for an underlying medical condition versus using the diagnosis of developmental delay. Discuss this with your doctor when getting a prescription for the services you are trying to get covered.
  4. Make sure your providers have updated insurance information as well as copies of your insurance card, front and back.
  5. Have authorizations in place before beginning services. Get copies of the authorizations and give copies to your provider. It is best not to get just a verbal authorization.
  6. If possible, schedule only a couple of sessions and allow claims to get processed before proceeding. You should see a trend with these claims. Remember, it takes up to 30 days for your insurance to process a single claim. Potentially a number of services could be rendered within this 30 days, costing your family quite a bit if insurance decides not to pay these claims.
  7. Open your mail/email correspondence from your insurance company as soon as possible. You will know about denials before your providers. Call your providers to let them know about any denials and decide if you will continue services while you work to get denials overturned. Remember that if your insurance continues to deny the claims despite your appeals, you are ultimately responsible for paying these claims.
  8. Call your insurance and ALWAYS document who you spoke to, the time and date and get a reference number for each call. This will help with following up.
  9. If you are not getting the help you wanted on the call to your insurance company, have the call escalated to a supervisor or manager. Remember, you are the owner of the policy; you have more pull than providers do with your insurance. Don’t be afraid to raise your voice.
  10. Consider a three-way call between you, your insurance company and a provider. This will allow everyone involved to have the same information and will eliminate the “he said, she said” dilemma.
  11. Ask your primary care provider or specialist to provide a letter of medical necessity and give it to all providers. Make sure to have the letter updated annually.
  12. Appeal all denials. Each claim denial will come with the rules on appealing, so follow the appeal guidelines and remember there may be a deadline to file appeals. Send medical records, prescriptions and letters of medical necessity along with appeals. Keep copies for your records.
  13. If all else fails: Contact the human resources department that provides your insurance to see if there is someone who can help with policy issues. For instance, Illinois law mandates that autism services be covered, but this does not apply to self-funded insurance plans. Exploring other funding sources, such as foundations or buying an individual policy for just your child to cover needed services, may be another option.

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