How to Check Your Insurance Benefit
Coverage
As
noted on the Insurance Information sheet that you completed, “We will do
our best to determine your insurance benefits; however, it is your
responsibility to know your insurance benefits, i.e., deductibles, co-pays,
visit limitations, etc., and to be responsible for them. We are providers for
most insurances but not all. You will be responsible to reimburse Capernaum the
patient responsibility portion of your insurance plan and/or if we are out of
network.”
Prior to your child’s appointment, we will contact your insurance company to determine as best we can if services are covered. However, it is important that you understand your plan’s coverage as well. Follow the outlined steps below in order to check your coverage:
Contact member services. Their phone number will be on the back of your insurance card. Be sure to have your ID and group number ready and follow the prompts.
Speak the word “representative” if you get stuck in an automated system. Most times this will connect you with someone you can talk to directly.
You will be asked what benefit you are checking – physical, occupational or speech therapy. (Note that services will be considered habilitative unless it is the result of an illness or injury. Rehabilitative therapy helps a person regain a skill they have had in the past).
Things you will want to ask:
o What is my co-pay for (PT/OT/ST) therapy in the
clinic?
o If your child meets our home-based guidelines, does
your insurance cover home-based PT/OT/ST services?
o If my child has multiple therapy appointments on the
same day, will I be charged a co-pay for each session?
o Is there a deductible? If so, how much of that
deductible has been satisfied?
o Is there a co-insurance? If so, what is my portion? (Co-insurance
is the percent you are required to pay. For example, the insurance company may
pay 80%; therefore, your portion is 20%.)
o Is there a visit limit? If so, how many visits are
allowed each year, and how many visits have been used? Is that combined with
any other discipline (i.e., 60 visit combined limit for OT, PT, ST,
chiropractic)?
o Does my plan require a referral?
o Are there any other limits such as age or
illness/injury?
o My child has been diagnosed with ______________
(i.e., development delay, autism, etc.). Is this a covered diagnosis under my
plan?
o Write down the
name of the insurance representative and the date you spoke with them.
