Out of Network Benefits

If you have out-of-network benefits, here is a script you can use when you call your health plan to find out whether my services will be covered:

First, have your health insurance card and member ID ready as well as the date of birth and social security number for the caregiver who is the main policy holder.

Introduction:

"Hi, my name is [Your Name], and I’m calling to ask about my out-of-network benefits for speech therapy services for my child. Could I please confirm your name and job title for my records?"

(Wait for a response and write down the representative’s name and title.)

"I’d like to understand my benefits for CPT codes 92507 (speech therapy) and 92523 (speech therapy with evaluation of language comprehension and expression). Could you help me with this?"

Specific Questions:

1. Coverage Details:

   • "Are these CPT codes covered under my out-of-network benefits?"

   • "If they are covered, how much does the plan reimburse for these codes?"

2. Cost Sharing:

   • "What is my out-of-network deductible, and how much of it has been met so far?"

   • "Do I need to pay a copay or coinsurance for these services? If so, how much is it?"

3. Limits and Requirements:

   • "Is there a limit on the number of speech therapy sessions I can use per year?"

   • "Are there any specific requirements, such as prior authorization, a physician’s referral, or proof of medical necessity, for these services to be covered?"

4. Claim Submission:

   • Where should I send the claim forms, and what documentation do I need to include?"

5. Reimbursement Process:

   • "How long does it typically take to process a claim for out-of-network services?"

   • "Is there a way to check the status of my claims after they are submitted?"

Closing the Call:

"Thank you for explaining all of this to me. Can you confirm where I can find this information in writing, such as on your website or in my plan documents? Also, is there a reference number for this call?"

(Write down the reference number, if provided.)

"Thanks again for your time and assistance!"