Insurance

Insurance can be a valuable resource for covering the cost of essential therapy services. We accept various insurance plans, including PPOs, HMOs, and Medicaid. We work closely with families to navigate the complexities of insurance coverage. Understanding the concept of medical necessity is a crucial factor in determining insurance approval. This page explains what steps to take before services begin and offers tips on understanding your insurance benefits.

What is Medical Necessity?

Medical necessity is a term used by insurance companies to describe services that are needed to diagnose or treat a medical condition. Insurance companies want to ensure the service(s) your child needs is vital to their health and development.

Our team works hard to prove that your child’s services are medically necessary. We use standardized tests, detailed treatment plans, and careful documentation to track your child’s progress. This information helps us show insurance companies why your child needs therapy and why it’s important for their development.

Before Services Begin

To ensure a timely start to your child’s services, please provide the following:

• A physician’s prescription: Your child’s pediatrician or family doctor must prescribe the necessary services. This prescription should include patient information, date of referral, diagnosis (ICD-10), recommended treatment duration and frequency, and the doctor’s signature.
• Insurance information: We’ll need a copy of your child’s insurance card(s). This allows us to verify coverage, determine co-pays or deductibles, and obtain any required pre-authorization.
• Completed patient information: Complete the patient intake packet provided by our office team.
• Insurance authorization: We will obtain the necessary authorization from your insurance company.

Understand Your Insurance Benefits

When navigating your insurance benefits, it’s important to understand what your plan covers and any potential out-of-pocket costs. To ensure you make the most of your benefits and avoid unexpected expenses, here are some key questions to ask your insurance provider:

• What therapy is covered?
  • Is speech therapy, occupational therapy, physical therapy, or behavior therapy included in your benefit plan?
• What services are covered?
  • Are evaluations and ongoing therapy sessions covered under your plan?
• What conditions are covered?
  • Does your plan cover specific conditions such as autism, developmental delays, or speech & language disorders?
• What are my out-of-pocket expenses?
  • Do you have a co-payment or deductible for therapy services?
• What are my policy limitations?
  • Are there maximum visits per year or coverage exclusions you should be aware of?
• Is Total Education Solutions dba TES Therapy an in-network or out-of-network provider?
  • How do your benefits differ if using an in-network versus an out-of-network provider?

For Current Clients