How a Therapy Visit Becomes an Insurance Claim and Gets Processed for Payment
Understanding how your child’s therapy visit translates into an insurance claim and payment process can be helpful for parents navigating the often confusing world of healthcare billing. Here’s a straightforward look at each step involved, from your therapy appointment to the point where insurance either approves or denies payment.
1. The Therapy Visit
During the appointment, the therapist will record details about your child’s visit, including the type of therapy and any specific diagnoses or procedures.
This documentation is crucial because it helps establish the medical necessity of your treatment and is essential for submitting an insurance claim.
2. Coding and Claim Preparation
After your visit, your therapist and their billing staff prepare to submit a claim to your insurance. This involves translating your therapy session details into specific medical codes:
CPT (Current Procedural Terminology) Codes: These represent the type of therapy you received (e.g., speech therapy, physical therapy, occupational therapy).
ICD (International Classification of Diseases) Codes: These are diagnostic codes that help explain the reason for your therapy (e.g., speech delay, autism, developmental delays).
The use of accurate coding is crucial, as it directly impacts how insurance will reimburse. Missteps here can lead to claim denials or delays.
3. Submitting the Claim to Insurance
Once the coding is complete, the claim is submitted to your insurance company, often electronically, for faster processing. The claim will typically include:
Patient information (name, date of birth, insurance ID number)
Provider information (name, NPI number, and practice details)
Service details (dates, codes, and total charges)
4. Insurance Claim Processing
When your insurance company receives the claim, it goes through a multi-step review:
Eligibility Check: Insurance verifies whether your policy was active on the date of service.
Benefit Verification: The insurer reviews your specific plan details, such as co-pays, deductibles, and coverage limits.
Medical Necessity Check: The insurance may also verify that the therapy is necessary based on your diagnosis.
The insurance company then processes the claim based on their fee schedules, which outline the maximum allowed payment for different services. These amounts are determined by the contract between your insurance company and your provider.
5. Claim Decision and Explanation of Benefits (EOB)
After the review, insurance will either approve or deny the claim:
Approved Claims: The insurer will issue payment to your provider or, in some cases, directly to you if you paid out of pocket.
Denied Claims: If the claim is denied, the insurer will provide a reason, such as lack of coverage or insufficient information.
The outcome of the claim will appear on an Explanation of Benefits (EOB) statement, which shows:
The amount billed
The allowed amount (based on the insurer’s fee schedule)
What insurance paid
Any amount you owe (e.g., co-pays, deductibles, non-covered charges)
6. Payment and Patient Responsibility
Our office collects an estimated payment/copay on the date of service. If the claim is approved, the insurer will pay the allowed amount to the therapist, often within a few weeks. If there’s a balance left (due to co-insurance, deductibles, or other non-covered services), you will be billed by our office.
If the claim is denied, you may have the opportunity to appeal the decision by providing additional information or requesting a re-evaluation. You are still responsible for payment to the provider even if your insurance does not pay for the service, however we offer private pay rates and package discounts to help with that cost. We can also offer payment plans to spread out any larger balances.
Key Takeaways
Each therapy visit requires accurate coding and detailed claim submission to streamline the insurance process.
Insurers verify eligibility, benefits, and medical necessity before making a payment decision.
Patients should review EOB statements carefully and follow up on any denied claims to understand their options.
Understanding these steps can help demystify the insurance process, ensuring that you know what to expect and can act if there’s a billing or coverage issue. Our billing team is always ready to help you understand your benefits and billing questions. You can text 859-475-4305 and let us know you have a billing question or you can email us at billing@wilsonpediatric.com, someone from our team will be happy to assist you in any way we can.
