italk insurance protocol

Talking to insurance is an acquired skill - it’s definitely not something that comes intuitively! Here is a cheat sheet to get through to insurance more efficiently and effectively.

Insurance Phone Numbers:

Use the Insurance Calls Sheet to document when calling insurance

Keep in mind professional Phone Call Etiquette:

It is to our benefit that we talk clearly and concisely - there are many insurance customer or claims representatives whose dominant language is clearly not English.

Please help reduce frustrations for both parties by being patient and articulate.

For example:
- provide words to support the appropriate spelling; that’s N as in Nancy, M as in Mary

Script for Checking for Eligibility & Benefits

Have the following ready:

When asked:

  1. Medical or behavioral health? —> Medical.

  2. Inpatient or outpatient? —> Outpatient, office setting

  3. Who is the provider? —>
    - italk Speech and Language Center, 2460 Lemoine Ave Suite 502, Fort Lee, NJ, 07024
    - KyungHae Hwang

  4. What CPT Code? —> 92507 (treatment), 92523 (evaluation)

  5. If they ask for a diagnosis —> F80.2 Mixed Receptive-Expressive Language Disorder, F84.0 Autism Spectrum Disorder

Responsibility:

It is CAST’s responsibility to:

  1. Receive relevant information from new clients to call and check for eligibility and benefits with insurance

  2. Document the reference number for the call

  3. Update the client/caregiver on their insurance expectations prior to scheduling the evaluation:
    (ex. Hello Malang,
    Thank you for your patience in waiting for our call. After checking with your insurance, we can let you know that the evaluation will be covered with a copay of $25. In terms of therapy, you are covered X amount of visits. (if pre-auth is needed: It could take about 1-2 weeks to start therapy because pre-authorization report submission is required). Ms. Loopy is able to see you for an evaluation next Monday at 2 PM, if you can confirm.
    Looking forward to seeing you!)

Pre-Authorizations

What is the protocol to follow when a pre-authorization is required to start services?

  • All NJ FamilyCare insurances (Fidelis, Amerigroup) requires a prescription as well as a pre-authorization report to start speech therapy services: 92507.

    There are others such as:

    • Horizon BCBS of NJ

    • Empire

    • Emblem Health

    • Anthem

  • Once the prescription is received after the initial phone call with the client/caregiver, it is saved to the Drive and sent to the appropriate insurance using their systems. Use the Bill to/Insurance document to find the appropriate websites.

    After the initial evaluation is completed, the clinician sends the Pre-Authorization report within two weeks of the evaluation date. It is then sent to the insurance by the Reception Team using the appropriate systems.

  • Continuing pre-authorizations are due two weeks prior to the ending date for the clinicians. It is the clinician's responsibility to:

    • submit the reports in a timely manner to the Reception Team using the Google Chat space

    • receive pre-auth period dates from the Reception Team and put it into the Master Caseload

    Reception Team submits the continuing pre-authorization on the day of the ending date. It is the Reception Team's responsibility to:

    • mark the calendars for the client's pre-auth ending period

    • send fax information to the clinicians regarding approval, partial approval or denials as well as the reasons for denials and information regarding requests for peer-to-peer review or other supplementary documentation needed

  • Should the insurance request for supplementary documentation, it is the Reception Team's responsibility to:

    • promptly notify the clinician of the requirements and due dates

    • send the documents in a timely manner to insurance to ensure best opportunity to continue services