Health Insurance FAQ

No, Clarity Speech Therapy is out of network with all insurance companies and is considered private pay only. Meaning that you are solely responsible for all fees with payment due at the time of service. 

If you wish to find an in-network provider, I encourage you to contact your insurance company to find providers in the area. Sadly, due to very low reimbursement rates, there are very few private practices who accept insurance, but they do exist! I also encourage you to ask you PCP for more information. If you have the desire, I encourage you to write a letter to your state representative regarding the desperate shortage of speech-language pathologists in California and low reimbursement for services (as insurance rates reflect the amount set by the state). 

Please know that due to state and national policy issues, Clarity Speech Therapy is unable to accept patients who qualify for Medicare or MediCal. If you also qualify for these services and receive EBT, I reserve a small portion of my weekly sessions for pro bono services. There is often a waitlist, but I will try! 

If you plan to navigate insurance, it is the client/caregiver’s sole responsibility to contact their insurance plan to secure any necessary pre-authorizations or required documents PRIOR to starting services. 

You will be provided with an insurance receipt commonly call a “Superbill” (with the diagnostic and procedure codes on it) to support your insurance claim. Provision of an insurance receipt (“Superbill”) does not guarantee reimbursement from your insurance provider. Clarity Speech Therapy does not get involved with the insurance company nor respond to any requests from insurance. We are happy to respond to your requests to provide documentation but will require your permission to do so. All administrative time is be billed in 15-minute increments of the hourly rate. When you ask for support, please let me know the upper limit of the time allowed. It is not uncommon for me to call an insurance company, only to be placed on hold for up to 2 hours and then accidentally disconnected by an agent when transferring the call. 

Many insurance companies will ask, so please know that your therapist is a licensed Speech—Language Pathologist. The California speech-language pathology license, American Speech-Language Hearing Association (ASHA) license, and National Provider Identifier numbers will all be listed on the insurance receipt (“Superbill”).

The current fee and attendance policy is available in the online system once you book an intake call. Please know that rates increase every January 1 informed by the Cost of Living Index announcement and actual changes in the cost of doing business. 

The following codes are based on typical referrals to this specific practice and cannot be confirmed until an in depth assessment has been completed. The most common codes at Clarity Speech Therapy are:

Diagnostic Codes (ICD-10):

• M26.59 (Abnormal jaw closure/malocclusion due to: Abnormal swallowing; mouth breathing; tongue, lip, or finger habits)
• R13.11 (Dysphagia, oral phase)
• R06.5 (Mouth breathing)
• R09.89 (Other specified symptoms and signs involving the circulatory and respiratory systems: Feeling of foreign body in throat, Choking sensation)
• R47.89 (Other speech disturbances)
• F80.0 (Specific speech articulation disorder)
• Q38.1 (Ankyloglossia)
• K13.0 (Diseases of the lips: Lip incompetence)

Procedure Codes (CPT):

• Assessment: 92610 (Evaluation of swallowing function)
• Assessment: 92522 (Evaluation of speech sound production)
• Therapy: 92526 (Oral function/swallowing therapy)
• Therapy: 92507 (Speech therapy).

Modifiers:

• Modifier -95 (Telehealth services)
• Modifier -52 (shortened services, used for on 15 minute check in sessions)

*An incorrect modifier is the most common cause for a rejected claim, so please be sure to ask! If the modifier your company requests is appropriate, I will happily add it in. Often it is as simple as adding/removing a hyphen. 

If you have any other medical documents/reports with codes, please share as this can help with understanding your case history. Also some codes are limited to one profession, but if there is documentation can be added to the assessment report. 

Reimbursement will be HIGHLY VARIABLE by plan. My experience with most major insurance companies locally indicate that some will reimburse everything less a copay and others absolutely nothing, with the cast majority somewhere in between. Recall, that you/the client are solely responsible for the cost of all services no matter what happens on your insurance journey. 

Many large employers have dedicated agents to help you navigate your health insurance and help you appeal insurance decisions. I encourage you to work closely with these agents! 

The following questions are not intended to be an exhaustive list, but START the conversation with your insurance company. 

• Does your policy cover Speech—Language Therapy?
• Does the insurance company require a specific modifier for services (e.g., GN, GT, 96)? An incorrect modifier is the most common cause for a rejected claim, so please be sure to ask! If the modifier your company requests is appropriate, I will happily add it in. Some companies need specific formatting to process claims (e.g.,  ask if your provider specifically does or does not want the hyphen).
• Do you cover out-of-network providers for speech-language therapy services? If they say no, ask about the process for GAP coverage. It may take some paperwork, but is often worth it! You may also wish to ask for a list of in-network providers who are currently accepting patients for your specific con=cerns.
• Do you cover sessions delivered via telehealth? Please be sure to check this specially for the procedure codes listed above. Some companies cover Telehealth but only for very specific codes or they require a different modifier (typically 95).
• Are there any conditions on what kinds of speech and language disorders are covered?​ Sometimes the answer is yes, such as no coverage for “developmental concerns” and coverage only if there has been an “accident/injury” or another diagnosis (e.g., Autism or Parkinson disease) which is related to the presenting concern. This could mean that speech therapy is not covered even if the codes are listed in your plan.
• Are there any financial limitations on this coverage, such as the number of visits allowed per year or the percentage covered if out-of-network? If you have a medical/health savings plan or flexible spending account, those funds may be used to cover evaluation and therapy services.
• How many sessions/dollar amount do they allow per treatment period, calendar year, or lifetime?
• Do they require supporting documentation or a referral from a medical or dental provider? If yes, even if you have coverage, without supporting documentation, services won’t be covered. 
• Do you require an assessment report or progress reports at specific intervals? For re-evaluation a report is not typically provided; your insurance may require a full quick summary or an re-evaluation report. Let me know! 
• Do you require a referral/prescription from a physician? Many insurance companies do not require this, but it is better to ask! Know that some companies require BOTH a referral and a prescription from your primary care provider (or other medical specialist).
• To whom does the company send the payment? What is the protocol to ensure payment is sent to the client/parent?  As I do not open information from your insurance company, if they are sending me a check, I will not receive it. For many companies, you may need to add the writing paid in full to the bottom of all "superbills."
• If you pay with your HSA or FSA card, can you apply for reimbursement from insurance? If you use HSA/FSA card to pay for services you may not be able to apply for reimbursement from insurance. Check your plan or financial advisor for more information. https://www.healthcare.gov/have-job-based-coverage/flexible-spending-accounts/

I can't know what this looks like for your insurance provider. 

Some companies require special hard copy forms to be completed, others have online portals where you can upload documents (e.g., superbills or daily notes). 

Some allow you to submit, others ask to have a duplicate faxed over by your provider. I am more than happy to fax over "superbills" or daily notes. I limit faxing of the same document to the same company to two times. Sadly, many of the fax machines at insurance companies seem to me unmanned and documents get lost. To prevent this from being an issue, I encourage you to upload the documents to your portal or get the name and direct fax line of an agent who is assigned to you. 

Some companies need a full evaluation summary others don't, some need this after a set time or session based intervals (e.g., after 10 sessions or monthly). These will incur an additional cost. 

Meaning, this varies widely and you need to ask questions about the exact policies and procedures required by your insurance company and your policy. 

I can't know what this looks like for your specific benefits.

Clarity Speech Therapy accepts most health spending account (HSA) and flexible spending account (FSA) cards through the online payment system/secure client portal. There gave been a couple instances where the card did not work (e.g., required a PIN, out of funds). 

Many companies allow you to apply for reimbursement from your HSA or FSA after the fact, but you will need to submit a receipt. If submitting, some companies require a form to be completed you are welcome to pre-fill the form and email it to me for a signature. 

Know that if you use your HSA or FSA to pay for services, this may forfeit your ability to apply for insurance reimbursement. It is always best to check with your insurance company/policy to find out details and requirements.

Clarity Speech Therapy's rates are based on clinical expertise/specialization as well as the physical location of the practice and local costs (Mountain View/Palo Alto).

Other providers especially those a little further away, will likely have lower costs and, ergo, lower fees. 

For more information on out-of-network rates in your area, please consult https://www.fairhealthconsumer.org/medical/select-medical-totalcost 

Other questions or specific needs, please ask!  I will do my best to support you 🙂 

Christina