| Insurance
Milestones is an 'in network" provider for most major insurance
plans and will file claims on your behalf. In cases we are not
"in network", you will be expected to pay for services in full
and submit to your insurance company for reimbursement.
- Aetna
- Blue Cross Blue Shield
- Cigna
- Great West
- Humana
- United Healthcare (speech/language therapy and feeding therapy only)
Insurance Coverage - Know the facts
- Be a smart consumer – Know your coverage
- While an insurance plan may provide benefits for occupational, physical or speech therapy, there are often specific. Common exclusions and limitations may include:
- Exclusions for diagnoses related to developmental delay or educational in nature
- Speech coverage only for children under three years of age
- Coverage for therapy only when therapy is required due to injury or congenital condition
- A limitation of the number of therapy visits per year or per authorization.
- Some plans require a referral and/or “pre-authorization” where the services you wish to receive must be approved by your carrier in advance. This may be required once for the duration your child receives therapy, once per year, or per each block of visits granted.
- Many larger companies and institutions with thousands of employees are "self-funded" and set the scope of coverage for their employees. The insurance carriers used by those companies are administrators who merely manage claims. The reimbursements for the claims paid out come from a pool of funds held by that company or institution. The benefits for a particular type of service may be better or worse than the generic plans offered by your plan's third party administrator. The first step in establishing benefits is to speak with your company's HR department to get the correct contact information for your plan's 3rd party administrator.
- Avoid surprises – Document
- Document the date time of any discussions you have with your insurance carrier or plan’s third party administrator, including the name of the representative you speak with. Having this information carries weight if there is later a dispute over coverage.
- Know that when an insurance company representative provides a quote of benefits, it not considered a guarantee of coverage or payment.
- Always specifically ask for limitations or exclusions to coverage. When seeking coverage information for multiple services, establish whether limitations and/or exclusions apply to each service or to the group of services.
- Establish what your deductible and out of pocket maximum is, how much of the deductible you have met, and your coverage for the services you are seeking once your out of pocket maximum has been met.
- Ask the representative to repeat back to you the facts you believe you have received.
- Catch problems early – Read your EOBs
- An Explanation Of Benefits is generated for each claim submitted to your insurance company and (EOB) is your guide to the services you have received, what you were charged and how much you owe(d).
- You and your provider receive identical information, typically 45 or days or less after a visit.
- It may take some time before payment issues are identified by your provider. If you think you see a problem, contact your health care provider’s billing administrator immediately. You are ultimately responsible for any services not paid by your insurance company
- Go here for examples of typical EOBs and how to decipher them.
- Your company's Human Resources department is there for you – Use them
- Your HR department manages your health plan and should be your primary resource should you not understand your coverage.
What can I do if therapy services are not covered?
- Check with your HR department to see if they have any special reimbursement programs for either the services being sought or the condition being treated.
- Call your state’s health/human welfare agency to see if there are any financial assistance programs.
- Occasionally, Milestones may provide services to a limited number of patients on a “pro bono” basis or at a reduced cost. This is offered solely at our discretion and is typically reserved for patients who have exhausted their benefits or who have absolutely no means to pay for therapy services; Qualification is based on financial ability, your child’s diagnosis and needs and your commitment to regular attendance and participation in therapy services.
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