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A Step-by-Step Guide to Processing a Claim for Out-of-Network Benefits

When you love your therapist at PSLLC but we don’t take insurance, understanding your out of network benefits coverage is crucial.  We recognize the insurance claim process is frustrating and can change daily depending on who you speak with at your insurance company.  Therefore, it is important to know how to process a claim for out-of-network benefits. This guide will walk you through the steps to assist in your claim submission.

Step 1: Review your insurance policy

It is essential to review your insurance policy.  Familiarize yourself with the terms and conditions of your coverage, specifically related to out-of-network benefits.  Pay attention to any limitations, deductibles, and reimbursement rates. Verification of benefits is not a guarantee of coverage or payment. 

When calling your insurance company to inquire about coverage, ask if medical necessity is required for therapy coverage.  If it is, we often recommend asking your pediatrician to write a prescription for the evaluation/therapy to be provided. 

Our front desk will be able to give you the procedure codes (CPT) used for the specific service you are receiving.

Step 2: Gather all relevant information

After receiving treatment, you will receive an itemized receipt in your email.  Notice on the receipt is our name and address (Princeton Speech-Language & Learning Center, 615 Executive Drive, Princeton, NJ  08540) our NPI# (1346411717), our tax ID # (22-3388799), phone and fax numbers, the diagnosis code (ICD-10 Code) and the procedure code (CPT).  In addition, the name and credentials of your clinician will be on your receipt. It is crucial to keep all documentation organized for the claim submission process.

Step 3: Complete the Claim Form

Obtain the necessary claim form from your insurance company.  Fill out the form accurately, providing all required information, including your policy number, personal details, and the details of PSLLC.  Attach the itemized bill and any supporting reports/evaluations to support the necessity of the therapy. (It is important to indicate on the claim that any reimbursement should be sent to the insured and not the therapy provider.)

Step 4: Submit the Claim

Submit the completed claim form along with the supporting documents to your insurance company.  Be sure to follow the preferred method of submission outlined by your carrier.  This may include mailing the documents or submitting them electronically through an online portal. Submit claims in a timely manner (within 7-14 days) from your date of service and follow up within 14 days of your claim submission.  Timeliness is essential when managing the claims process.

Step 5: Follow-up and Track

After submitting your claim, keep track of its progress.  Follow up with your insurance company to ensure it has received the claim and all necessary documents.  Take note of any reference numbers or confirmation emails for future reference.  Include reference numbers in all correspondence about the claim.

Step 6: Review the Explanation of Benefits (EOB)

Once your claim has been processed, your insurance company will send you an Explanation of Benefits (EOB).  This outlines the details of the claim, including the amount covered and any deductions or adjustments made. If the claim is denied, it will give an explanation and procedures for the appeal process. 

Processing a claim for out-of-network benefits can be a complex and frustrating process.  By following these steps and adding a little bit of patience, you can navigate the process with confidence.  By staying organized and proactive, you can maximize your chances of receiving reimbursement for out-of-network services.

Helpful Hint:  If you have a FSA or HSA that uses a MC/Visa, we can use that to pay for your therapy charges.

Flexible Spending Account (FSA) – This is a pre-tax benefit most employers offer in which you can utilize pre-tax dollars that you put into your FSA for medical costs inclusive of therapy, dentist, healthcare, etc.

Health Savings Account (HAS) – This is a savings account used in conjunction with a high-deductible health insurance policy that allows users to save money tax-free against medical expenses.

GAP Exception – A network gap exception is a tool health insurance providers use to compensate for gaps in their network of contracted healthcare providers.  This is a way that clients may be able to access “in-network benefit coverage” from an out-of-network service provider.  This is specifically useful when submitting claims for our social communication groups.  All of our speech therapists are specifically trained in the social thinking curriculum and therefore this specific training separates PSLLC therapists from the majority of in-network providers that do not have the training.