We know that for many people, understanding the logistics of insurance coverage can be daunting. At CI, the Insurance and Billing team is committed to providing the best possible resource for families seeking therapy services. We will investigate your insurance benefits, submit for prior authorizations if needed, bill services to your carrier and also work on any denied claims. We are here to help answer your questions and concerns with insurance billing!
While our team works to help you understand your insurance, sometimes it may be necessary for you, the member, to call your insurance carrier to get more information, such as determining the way in which claims are processed or why services are no longer covered.
We’ve outlined the typical process for submitting for authorization, the different types of denials we see, as well as a list of commonly used insurance terminology.
The Process for Insurance Benefit Checks/Authorization:
- Once a family contacts CI inquiring about services, they will fill out the Intake paperwork along with the insurance information.
- Once it gets to our billing department, we will check your plan benefits by either website confirmation or by calling your insurance carrier for policy specifics regarding the therapy you are inquiring about. We will then reach out to the family and discuss your policy’s benefits, deductibles, maximum out of pocket, and copayment amounts.
- We will determine if an authorization is needed before services can start and will submit these requests on your behalf.
- If the authorization is approved, we will send information back to the intake team so the clinic of your choice can reach out to you to arrange scheduling.
- If the authorization is denied, someone will contact you to go over the denial reason as well as discuss the options moving forward.
DENIALS: There can be two different denials.
- Prior Authorization Denial: Your insurance company may deny a prior authorization for some of the following reasons;
- The diagnosis code or the therapy being authorized is an exclusion on your policy.
- CI might be considered an out of network provider. Some policies will not have any out of network benefits.
- If the client has been seen for a while, the prior authorization may be denied due to “maintenance therapy”.
- Claim Denial: A date of service that has been sent to your insurance company for payment may be denied due to these reasons
- Denied due to no authorization on file.
- Denied due to no habilitative coverage on your policy
- Diagnosis codes are not billable, exclusion on your policy
- Insurance coverage was not in effect on the date of service
- Maximum visits being used per your policy guidelines
Commonly Used Insurance Terminology:
- DEDUCTIBLE: Your deductible is the amount you’ll pay for covered services before your health insurance plan contributes. This deductible amount will reset at the end of the insurance service year or calendar year.
- CO-INSURANCE: Co-Insurance is the percentage of covered services you’re responsible to pay, while your insurance covers the other percentage. For example, if your insurance covers 80% of the cost of a service, you’ll be responsible for the remaining 20%.
- CO-PAY: Your co-pay is a predetermined dollar amount you will pay a healthcare provider for a covered service at the time of the visit. Co-payments vary from plan to plan, by service and in-network versus out-of-network.
- MAXIMUM OUT OF POCKET: Your out of pocket maximum is the maximum amount of money you will pay for covered services during the course of a benefit period. The out of pocket maximum varies from plan to plan, but can include co-pays, deductibles, and co-insurance. This will never include your premium, balance-billed charges or services your insurance plan does not cover. Once you’ve paid your full out of pocket maximum, your insurance will pay 100% of the allowed amount for your covered healthcare expenses.
- PRIOR AUTHORIZATION: Sometimes called precertification or prior approval – is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from your insurance carrier before a specific service is delivered to the patient to qualify for payment coverage. This does not mean that services will be covered at 100%. Most plans will still apply charges to any outstanding deductible or maximum out of pocket expense the member needs to satisfy.
- HABILITATION VERSUS REHABILITATION: Habilitative services help a person keep, learn, or improve skills and functions for daily living. Rehabilitative services, on the other hand, help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because of an illness or accident.
Want to learn more? Connect with us anytime over the phone (608) 819-6394, extension 1021 or via email at: firstname.lastname@example.org.
By: Amanda Gilbertson and Ann Roesch