Could there be anything more confusing than health insurance? Insurance plans vary widely from company to company, and even family to family (not to mention, year to year). It can often be hard to understand if your policy will pay for your child’s ABA therapy and how to submit your claim for reimbursement if it is required by the family and not the provider.

The best way to determine what your policy covers is to call up your insurance provider and ask the following questions.  Of course, we will also check with your insurance provider to verify before starting services and will assist you in this process every step of the way!

Is my child eligible for ABA therapy?

This is the first question to ask your insurance provider. Make sure you provide your child’s age as well as any diagnosis your child may have.

Your insurance company may only reimburse for certain treatments. For example, most of Alabama’s medical criteria for coverage is usually limited to Autism Spectrum Disorder, F84.0. ABA therapy for young children without a diagnosis, or with other possible diagnoses such as ADHD, ODD, or Downs Syndrome may not be covered.

Lastly, some insurance plans don’t cover ABA therapy for children above certain ages (often 9), so be sure to check any age limits with your provider.   

Do I need to obtain a prescription, referral, or pre-certification for therapy from a pediatrician?

A quick trip to your pediatrician may be needed before an insurance company is comfortable reimbursing therapy expenses. If you do need a prescription for therapy, explain your concerns to your child’s pediatrician and request that they provide a prescription to satisfy your insurer’s requirements. This will need to indicate the diagnosis, as well as ABA therapy. For Medicaid, they require a specific form to be filled out with this information, as does Tricare. Ask your pediatrician specifically about each of these as they must submit this information.

Most all insurance companies require preauthorization prior to the initial assessment and then also for the ongoing therapy. Re-authorization then occurs typically every six months.

It’s important to mention that you do not need a prescription (an Autism diagnosis, or insurance coverage to receive services from SBH), but most insurance companies do require these things for reimbursement.  We’re happy to work with any parent who may have concerns about their child’s behavior or skill acquisition through our private pay model.

How are out-of-network services treated under my policy?

We are in network with BCBS, Viva, Cigna, Medicaid, Optum/United, and Tricare so this should not be an issue if your policy has ABA coverage. However, it is possible that you may have a subsidiary plan that is not included and may consider us out of network. But that doesn’t mean your insurance company won’t reimburse for out-of-network services! Ask about your insurance policy’s benefits for out-of-network providers, specifically:

  • What rate are out-of-network benefits reimbursed?
    • For example, if your insurer covers 90% of eligible charges after meeting your deductible, you would be responsible for any payments until your deductible is met, and 10% of payments afterwards. Keep in mind that there may be a difference between the actual charge your out-of-network provider bills you and the “eligible” charge that your insurance company reimburses. 
  • Are there separate deductibles for in-network vs out-of-network benefits?

What documentation is required?

At SBH, we provide a bill describing exactly what services were rendered, ICD-10 diagnosis codes specific to your child’s diagnosis, charges and CPT codes for each treatment, as well as detailed office notes. We will file all claims to your insurance, and you will receive an invoice with your copay, co-insurance, or deductible amount owed, depending on your policy.

Should you need to file the claim yourself (out of network plan or no coverage you want to fight) when you’re ready to file your claim, your insurer will require documentation from the therapist. Often, this information can be found on the medical expense claim form you will use to submit your claim (ask your insurer to provide this form or check their website for it).

And of course, we are more than willing to provide any other information your insurance company needs.

How long / how many therapy sessions are allowed?

Typically, there is a limitation on the number of hours (40 per week) for services depending on the age of the child, declining as age increases, or total dollar amounts for the calendar year that follow the same pattern. In some cases, set limits on the number of sessions or months that therapy will be covered, such as 30 visits per year can occur, however this is rare for ABA to be included in this small limit. However, keep in mind that many insurers count all types of therapy (speech, occupational, physical) towards this limit, so be sure to check with your insurer if your child is receiving other types of therapy.

You’ve got this!

Having your child’s ABA therapy covered by insurance may seem like a daunting challenge, but taken step-by-step, the hassle may be well worth it. By asking your insurance provider the questions above, you can better understand how your policy covers your child’s ABA therapy.

Don’t let insurance prevent you from providing your child with the support he or she needs. Speak with your HR department to see if ABA is a policy option that can be added as well, if this is something that is currently not offered.

We’re here to help you each step of the way. Speak with us today!

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