Interacting With Private Insurance Companies / Verification of Benefits

  1. Call the Benefits Verification department of the insurance carrier. The phone number can generally be found on the back of the insurance identification card. If you do not have a copy of the card, use the general phone number for the insurance company provided by the family on the EI Insurance Information form.
  2. Identify yourself as a provider and that you want to verify benefit coverage. Give the insurance company representative the name, social security number, employer and insurance group # for that employer, if available. The representative will ask you what type of benefits you are calling to verify (OT, PT, ST, Audiological, etc.)
  3. The representative will first tell you that the verification of benefit is a "quote only" and not a guarantee of payment to you. A final determination regarding reimbursement to you will be made when the actual claim is reviewed by the insurance company. The representative will tell you whether or not the service is covered, and what the rate of reimbursement is. For example, "This policy does have speech therapy benefits, payable at 80% of usual and customary charges, subject to a calendar year deductible of $250". That simply means that they will reimburse you for 80% of your fee, if your fee is considered reasonable for the service provided, and if the deductible for your client has already been met for the current calendar year. (More information about deductibles is provided elsewhere in this manual.)
  4. If the insurance representative does not volunteer any information to you about policy limitations, be sure to ask if there are any. Here are a few examples of limitations that an insurance company might have for speech therapy benefits:
    • A pre-certification, or pre-authorization is required
    • A referral must be made by the primary care physician
    • Services must be medically necessary
    • Services must be provided by a licensed S&LP (Speech & Language Pathologist)
    • Limited number of visits per year
    • Limited number of visits per diagnosis
    • Maximum amount payable per year
    • Maximum amount payable per lifetime
    • Reimbursement is made only for a particular diagnosis or event
    • Reimbursement is made only to preferred providers for their company
    • A lower rate of reimbursement may be available for non-preferred providers of their company
    • Benefits payable by insurance carriers generally have some type of limitations. Be sure to ask for them if they are not volunteered to you!*
  5. If you do not already have the address where your claims should be sent, be sure to ask for it. Many insurance carriers have separate claims-paying facilities, and if your claim is sent to the wrong address, it will add several weeks to the date you are reimbursed.
  6. Be sure to get the name of the person you spoke with, and write down the information you receive immediately. If you do not fully understand the quote, ask again, or feel free to call back.
  7. If there is benefit coverage, notify the family accordingly, so they are aware that their insurance will be billed for the services you provide. (It is possible that OT and PT may be covered, but not ST, or vice versa. Make sure the family understands which services will be billed to insurance, and which services will be billed only to the EI-CBO.)
  8. Initiate services, and once performed, bill the appropriate payer.