Your child has been referred to the Division of Speech-Language Pathology at Cincinnati Children’s Hospital Medical Center for an evaluation and possibly for treatment. We will assist you in accessing insurance benefits; however, we cannot schedule your child’s therapy until insurance authorization is obtained or you agree to self-pay.
Some insurance plans do not cover speech-language pathology services. Common reasons for denials include:
- Policy language: Most children are not covered if the benefit includes only disorders resulting from “accident, illness or injury.”
- Diagnosis: Some diagnoses may be excluded from coverage. Common exclusions include: developmental delay, language disorder, autism, auditory processing disorder, stuttering, congenital disorder (e.g., cleft palate).
- Services are considered “educational”: Many plans deny services for school-age children because they can receive therapy in school. Unfortunately, not all children are eligible for school therapy unless the disorder is determined to be “educationally handicapping.”
If your policy does not cover speech pathology services or if the coverage is limited:
- Find out if your employer offers another plan that provides better coverage for speech and language services and switch to that plan during the next open enrollment period.
- Inform your employer about the limitations in your plan and request better coverage in writing. Your employer’s human resources director may not realize the need for better speech therapy coverage unless you inform him or her. Improvements in coverage will occur only if people are willing to challenge the denials.
- Send a letter to your state legislator about the need for insurance reform.
If you have a speech pathology / therapy benefit, but coverage is denied:
- Call your insurance company to determine the reason for denial. Ask for a copy of your plan’s policy for speech therapy services and an explanation for the denial in writing. Write down whom you spoke with, the time and date and what was said for all telephone calls. Keep all fax confirmations. Ask about the appeals process, the mailing address for the appeals department and how long it will take to receive a response.
- Contact the benefits coordinator at your place of employment. Provide him or her with all documentation of your conversations with the insurance representative and copies of all letters sent and received. Ask the benefits coordinator to contact the insurance plan on your behalf.
- Contact your child’s pediatrician and referring physician and ask for a letter to be sent to the insurance company that supports your child’s need for therapy.
- Contact the speech-language pathologist if your child has had speech therapy. Request a recent progress report and an appeal letter.
- Write a letter to your insurance company asking to review the claim. A written inquiry will more likely result in a written response. Send all appeal documentation to your insurance company in one envelope via certified mail. Follow up with a phone call one or two weeks later to check on the status. Insurance companies typically require that you submit the appeal request within 30 days of receiving the initial denial of the claim.
- Contact our insurance specialist, Angelius Ellis, at firstname.lastname@example.org or by calling 513-636-3442.
- Submit a formal complaint to your state insurance commissioner. While the insurance commissioner may not investigate your case, the department does log all calls and if enough complaints are made, it may decide to investigate a particular issue.
Ohio Department of Insurance
Kentucky Department of Insurance
US Department of Labor
Pension and Welfare Benefits
Indiana Department of Insurance