How to Get Your Insurance Company to Cover Autism Treatment
While Christina's book, with its detailed information and worksheets, is only available through her website, she did share information with me about the steps to take to get started on finding insurance coverage for treatments such as occupational therapy, physical therapy, speech therapy and even Applied Behavior Analysis. It's also worth knowing that most of the national codes for autism-related health insurance are available, free of charge, at Insurance Help for Autism, a site dedicated to the subject (though focused largely on resources in California).
Peck also shared another critical piece of advice: do your insurance homework before you negotiate for services and programs with your school. Once you know what's covered, you're in a better position to bargain with the district. If you know, for example, that insurance will cover physical therapy for your child you might choose to forgo PT at school in exchange for a strong social skills program.
A small word to the wise: Ms. Peck's success is based on an extraordinary amount of patience and organization - not to mention a willingness to confront and battle with insurance companies, school districts and individual therapists. I have to admit that I don't have what it takes to follow in her footsteps; I've chosen to take my child out of school altogether and work with him on my own. For those with the right temperament, though, success is possible!
Comments
Another comment for parents seeking to have ABA covered by insurance from someone who was partially successful before it was mandated: One of the primary questions insurance companies will ask is what is the procedure code. The website refered to reccomends using 90806 and 90808 for ABA treatment codes. It is important to understand that these are mental health codes which are normally used for individual mental health “counselor” therapy. (I know my wife is one!) There are several problems with using these codes 1) They are mental health codes and if you claim that is what you are getting then most insurance policies have strict limitations on how many mental health visits you get per year. In effect you are giving them an excuse to deny you after covering about one week of ABA. 2) By using a “mental health” treatment you are in effect claiming that your child has a “mental health illness” as opposed to a regular illness or neurobiological illness, this is important because all other items which you may try to submit (testing, speech, PT, OT, doctors visits, supplements, etc) can be denied by an insurance company because these treatments are not “medically nessecary” for a “mental illness” 3) They are not really indicative at all of what you are getting and certainly don’t match as a prescribed treatment for a “diagnosis code” of 299 (autism). Soooo… What code do you use? Well currently there is no code for ABA treatment unless you are under the military Tricare system and I believe they have guidance that says to use an experimental code. The approach I took is to create a CMS-1500 claim form with all other information which is needed to file a claim, and leave the procedure code blank, and provide a clear description “1 hour Applied Behavioral Analysis Therapy under the supervision of a Board Certified Behavior Analyst” – Be sure to break it down in 1 hour hour increments (or smaller) as an insurance company will not have a way to understand “1 day”. This of course will get your claim bounced because it does not have a procedure code however I reccomend writing a letter (or better yet having your BCBA write it) that explains the AMA has not yet approved a code for ABA however all current best practice for the treatment of autism reccomends “Applied Behavioral Analysis Therapy under the supervision of a Board Certified Behavior Analyst” (carefull to use the same words on your claim) and request that the insurance company direct what code they prefer to use in future claims as this is clearly a covered service. Takes a bit longer (took me 12 months to get them to pay anything but I did eventually get a check for a pretty hefty sum).
Hope that helps someone… I strongly reccomend reading the entire insurance plan before submitting your first claim and understanding how new law may mandate coverage in your state as many states are passing new legislation mandating autism coverage. It has been my experience that the more knowledgable, professional, and patient you are the more likely the insurance company will pay. They love the ignorant angry ones!
Hope that helps someone!
-MikeBTexas
We have had some luck. Insurance has been paying for ABA for several years and some biomedical. My wife works like a DOG on insurance though. It’s to the point that we have wondered if we should hire an assistant to keep up with all of the paper work.
Recently, they said they would stop paying since our diagnosis is PDD-NOS unless we submitted a “treatment plan” from our doctor. My wife has put together a plan and it’s like a book or college thesis. I often think they just put up as many hoops as possible knowing most folks will give up jumping thru them.
Fielding
http://autismparents.net
Mike I’m a BCBA trying to figure out coding etc…I just got approved to be a tricare provider too. But I am still lost…can you give me any advice for me and my families? THanks
I goe Aetna to approved my ABA BCBA…got 1 claim reimbursed and now they are wanting a proceedure code…My therapist is unsure…I NEED HELP!!
I am an ABA therapist, the ins co will need a diagnosis code (299) and then a treatment code (97532) these are the codes I use and they work!!