UnitedHealthcare Children’s Foundation (UHCCF)

http://www.uhccf.org/

The UnitedHealthcare Children’s Foundation (UHCCF) is a 501(c)(3) charitable organization that provides medical grants to help children gain access to health-related services not covered, or not fully covered, by their parents’ commercial health insurance plan.


Families can receive up to $5,000 annually per child ($10,000 lifetime maximum per child), and do not need to have insurance through UnitedHealthcare to be eligible.

UHCCF was founded in 1999. Since 2007, UHCCF has awarded more than 8,500 grants valued at over $26M to children and their families across the United States. UHCCF’s funding is provided by contributions from individuals, corporations and UnitedHealth Group employees. 
The Foundation embraces and supports the concept of facilitating access to health-related services that have the potential to significantly enhance either the clinical condition or the quality of life of the child and that are not fully covered by the available commercial health insurance plan. The Foundation provides financial assistance toward the family's share of the cost of medical services.

Inquire About Eligibility and Benefits for Auditory Rehabilitation

Steps to Inquire About Eligibility and Benefits



Call the member services number on the back of your insurance card 
to inquire about eligibility and benefits for auditory rehabilitation.

Below are the CPT or procedure codes.

RE: THERAPY TYPE: Auditory (re)habilitation, Auditory-Verbal Therapy
CPT CODE: 92630 auditory rehab, prelingual hearing loss
CPT CODE: 92633 auditory rehab, postlingual hearing loss

RE: THERAPY TYPE: Auditory Processing Disorder
CPT CODE:  92626 Auditory Rehabilitation, 1st hour


Each plan is different and services may be subject to a deductible, coinsurance, or copayment.  Clients with Health Maintenance Organization (HMO) plans are responsible for getting a referral from the primary care physician prior to receiving services.  Lynn A. Wood is not responsible for denials on insurance claims, and clients are responsible to pay for services rendered.

Questions to Ask When Inquiring About Eligibility

It may be helpful for you to contact your insurance company and ask the following questions so you are aware of your insurance benefits.


1.    What are my outpatient benefits for auditory rehabilitation?

2.    Do I have a deductible?

3.    What is my co-pay or co-insurance percentage?

4.    How many visits do I get per calendar year?

5.    Do I need a referral or authorization prior to my visits? How often?

6.    Is my plan’s coverage of outpatient auditory rehabilitation based upon medical necessity? If so, what diagnoses are covered under “medical necessity”?

7.    What is the effective date of my coverage?

8.    Is Lynn A. Wood, M.A. CCC/A LSLS Cert. AVT in your provider network?

            NPI #: 1295853919

            Illinois Licensed Audiologist #147-000172

            Listening and Spoken Language Specialist, Certified Auditory-Verbal
            Therapist #70712318

9.    If not, who is an in network provider that is a Certified Auditory Verbal Therapist and a Licensed Rehabilitative Audiologist within 30 miles from my home?

10. If they do not have a provider in in network, request reimbursement at the in network rate.

Some insurance plans do not cover therapy services unless they are considered to be "medically necessary." Contact your insurance company to inquire about medical necessity guidelines that may apply to your plan

If services are denied, you have a right to appeal the health insurance company for speech-therapy coverage.  The American Speech-Language-Hearing Association (ASHA) has published a document on medical review guidelines that can be used as part of the appeals process.

Bottom Line: Private Health Plan AR Reimbursement




http://www.asha.org/uploadedFiles/practice/reimbursement/coding/AuralRehabforAudandSLP.pdfhttp://www.asha.org/uploadedFiles/practice/reimbursement/coding/AuralRehabforAudandSLP.pdf

Hearing Loss Plus - Applying for Disability Benefits


A communication impairment can significantly impact your child's ability to function on a level similar to his or her peers. Specialized therapy, assistive technology, and medical attention—all integral parts of recovery—can be very costly. 

If your child has a communication disorder and you cannot afford to support their specific needs, you may qualify for Social Security Disability benefits on his or her behalf. If your child has a hearing loss as  either as a primary condition or associated with another injury or illness – then he or she may be eligible to receive disability benefits through the Social Security Administration’s (SSA’s): Supplemental Security Income (SSI) program and/or Social Security Disability Insurance (SSDI) program

Although the application process can seem complicated and overwhelming, disability benefits are often a necessary lifeline for many families. Once you are awarded benefits, you will be able to better support your child’s needs.

Starting Points:  

1. Eligibility for Benefits
A child under the age of 18 typically qualifies for Supplemental Security Income (SSI) rather than Social Security Disability Insurance (SSDI). This is because the SSDI program requires past employment and a specific amount of taxes paid into the system. However, if a child’s parent currently receives SSDI, the disabled child may be eligible for dependent benefits under that parent’s name. If you feel that your child may qualify for dependent benefits under a parent or guardian, contact the representative who handles the eligible parent’s claim.
SSI, on the other hand, pays benefits to elderly or disabled individuals who have access to very limited income. There are no work-related requirements for SSI—making this program the best option for children with disabilities. To qualify, applicants must meet very specific financial requirements. In the case of a child, a parent or guardian’s income will be evaluated. Learn about the specific financial limits, here: http://www.socialsecurity.gov/ssi/spotlights/spot-deeming.htm.

2. Disability in childhood
In addition to the technical requirements listed above, there is also a basic definition of disability that your son or daughter must meet. 
This is as follows:
-  Your child is considered disabled if he or she has an impairment (or combination of impairments) that causes pronounced and severe limitations or
-  Your child is disabled if he or she fails to meet age-specific developmental milestones as a result of a diagnosed medical condition.

3. Requirements based on medical conditions
If your child meets the basic definition of disability, his or her condition will be evaluated based on very specific medical requirements. These requirements can be found in the SSA’s guide of potentially disabling conditions, known as the blue book.  Although a specific diagnosis is not listed in the SSA’s blue book, your child may still qualify for disability benefits.
There are two ways in which your child may qualify for SSI without meeting a blue book listing:
- Match the specific medical criteria listed under a separate but similar listing
- Provide evidence that, despite not meeting a blue book listing, your child’s impairment causes significant difficulty completing age-appropriate activities of daily living.

You must provide thorough documentation of your child’s specific limitations. The SSA will use this information to complete the Childhood Evaluation Form (SSA-528), which is used to evaluate the severity of a child’s condition.

4. How to apply for benefits
The initial childhood application for SSI is comprised of two forms and a required interview. Many parents prefer to complete the necessary paperwork and their interview at the same time.
The first step toward applying is to schedule your appointment with the SSA. It will probably take some time before there is an available appointment date. Use the time in the interim to collect all of the necessary documentation, including: medical records, school records,and any other information that points to the limitations and challenges your child faces on a daily basis.
5. The application and review processes
Once you complete the initial application, it might be months before your receive a decision. You should be prepared to face the possibility that your child might be denied. If this happens, it is important that you do not give up. You have 60 days from receiving the denial to file an appeal.

UNDERSTANDING INSURANCE PLANS

Source
This article is adapted from © Jennifer Getch, MA CCC-SLP 
www.nwspeechtherapy.com/blog

First, talk to your Audiologist or Auditory-Verbal Therapist to determine which specific codes will be used for billing. You will need to know both the:
• The CPT procedure code(s)  
• ICD-9 diagnosis code(s)

When calling your insurance company to check on benefits for Auditory Rehabilitation, Auditory Verbal Therapy or Auditory Processing Therapy utilize the "cheat sheet" below.


Insurance Terminology


It can be daunting when dealing with insurance companies regarding the health coverage of auditory rehabilitation or auditory-verbal therapy sessions for you or your child. Below are some insurance terms you may come across when dealing with insurance.

Co-pay: People are most familiar with a co-pay. This is the specific amount of money that you pay for certain services. It may be $15 co-pay for a doctors visit, a $25 co-pay for a prescription but either way you know exactly how much you will need to pay and it DOES NOT change based on the cost of the service. You will pay your $15 co-pay whether the doctor charges $300 or $3000 for that service.

Co-insurance: This is the amount you will pay for each service and it is based on a ratio that is set by your plan. If your visit costs $100 and your plans co-insurance ratio is 80/20 then your insurance company will pay $80 and you will pay $20. If the same visit was $1000 then your insurance will pay $800 where you would pay $200. Therefore it DOES NOT stay the same as it is based on what the services cost. (NOTE: It is extremely rare for a health plan to have both a co-pay and a co-insurance that would be due for a particular service, it is usually one or the other.)

Deductible: This is the specified amount of money that you will pay out of pocket BEFORE insurance begins to cover any portion of the charges. It is important to specifically ask if a patients deductible has to be met prior to insurance kicking in as there are many plans that have a deductible, however, the patient does not have to meet the deductible for speech therapy services prior to insurance kicking in.

Maximum out-of-pocket: This is the maximum you will have to pay in a year. It is an accumulation of your deductible, co-pays and co- insurance. After the maximum out-of-pocket has been met then insurance will pay 100% for the remainder of charges.

Prior authorization: Prior authorization is pre-approval from your health insurance plan that the specified service WILL be covered. If your health plan requires prior authorization for a service then it is required for you to obtain this approval BEFORE you have the service done. Otherwise Insurance can deny it even though they may have otherwise covered it. Most health plans have forms on their websites to download, fill out and fax in to get this approval. You will need to send the evaluation report, if available.

CPT code: This is a 5 digit numerical code that is used to describe medical procedures. Common ones for Auditory Rehabilitation are:

CPT code 92626, Evaluation of Auditory Rehabilitation Status, first hour
CPT code 92630, auditory rehabilitation, prelingual hearing loss
CPT code 92633, auditory rehabilitation, postlingual hearing loss

 ICD-9 code: This is a coding system used to describe signs, symptoms, conditions, injuries or diseases. (NOTE: ICD-10 will begin in October 2013).

Exclusions: These are specific conditions (ICD-9 codes) not covered by an insurance plan.
Appeal: This is the course of action you can take when coverage of a service has been denied and you would like the insurance company to re-assess in the hopes that they may change their decision and cover the service previously denied.

Allowed amount: This is the amount that an insurance company bases their payment on. It is not necessarily the amount that the provider billed. For instance, the provider may bill $130 for a service however; the insurance company only allows $100 for that service so the co-insurance amount is based on that allowed amount and not the billed amount from the provider.

In-Network: Most insurance plans have different coverage based on whether the provider is "in-network or out-of-network". Co-pays, Co-insurance and deductibles are often lower for in-network providers. To be considered in-network, the provider has to have a contract signed with the insurance company. The downside to this, for a provider, is that this contract often limits the amounts that the provider can charge the insurance company for a particular service and the insurance company does not allow a provider to bill the patient for the amount over what insurance allows.

Out-of-network: Patients will often pay more for co-pays, co-insurance and deductibles when utilizing an out-of-network provider. They will also often incur the additional cost above what the insurances allowed amount is. Let’s say that your insurance allows a
provider to bill $250 for a particular service but that provider normally charges $300 for this service. If your co-pay is $25.00 then you will pay $25.00 in addition to the $50  not allowed by insurance. Especially with the big changes happening with health insurance, many providers choose to be out-of-network providers so that they do not have to take such a big deduction in their reimbursement rates.

Medical Necessity: Many insurance plans will only pay for services that they feel are "medically necessary", this often means that they will require reports from therapists, physicians, etc. and will utilize their own professionals to conduct an evaluation of these reports in determining if there is a medical necessity for the patient to receive the services in question.


Explanation of Benefits (EOB): This is a summary of the billed service where you are able to see what portion was applied to deductible/co-pay/co-insurance, etc. It will also tell you when services are denied and why.

Check Reimbursement Resource Guides such as:
http://apps.advancedbionics.com/cismart/CPTSummary.aspx



 FOR MORE INFORMATION

Insurance Guide for Parents:
http://www.listeningandspokenlanguage.org/Document.aspx?id=228

Reimbursement and coding:
http://www.audrehab.org/6%20Reimbursement%20Panel%20_Abel%20&%20White.pdf
http://www.audiologyonline.com/articles/audiology-cpt-code-changes-for-1001
http://www.asha.org/practice/reimbursement/coding/ar_reimbursement/