Common Reasons Why a Speech Therapy Insurance Claim is Denied

by Jacky G.

The term “health insurance company” might be synonymous with “red tape,” but your child does not have to be caught in the crosshairs. Understand the common reasons why an insurance claim for speech therapy might be denied before you submit the paperwork. Thoroughly review your healthcare policy and then submit the claim with all of the required supporting documents. Even if your claim does get rejected, you can always file an appeal.

Reason for Denial: “Medical Necessity”

Health insurance companies often refuse to cover any treatments that are not deemed “medically necessary.” That is, if the ailment is not known to have been caused by a definable disease, injury, or condition, the insurance company may deny the claim.

It is often difficult to determine the exact cause of a speech disorder. Many of them arise from neurological conditions, the specific causes of which are unknown. Without specific, supporting statements from your child’s doctor or speech therapist that insist that treatment is necessary, the health insurance company may deny the claim.

Reason for Denial: Developmental Disorder

Health insurance companies may also deny a claim because a certain speech disorder is considered to be a developmental disorder. The claims officer might interpret the term “developmental disorder” to automatically indicate that the child will “grow out of” the language impediment. While this can sometimes occur, it’s best to assume that your child does in fact need treatment. Even if your child’s speech disorder or delay is considered to be developmental, ask the speech therapist to avoid using that word and its corresponding medical billing code on any paperwork.

Reason for Denial: Public School Services

Your health insurance company may try to claim that because your child has access to speech therapy through the public school system, he does not need access to speech therapy in a clinic or another setting. Your child’s speech disorder does indeed have a significant impact on his educational development, but it is also a medical issue. After all, you wouldn’t take your child to see his teacher when he comes down with the flu.

Inform your health insurance company that numerous organizations officially recognize speech therapy as a healthcare service, such as the Health Insurance Association of America and the Joint Commission on Accreditation of Healthcare Organizations. Provide supporting documents that spell out exactly why your child requires private speech therapy. For example, the speech therapist in the school may have a long waiting list. Your child might also not qualify for services in school, depending on his standardized test scores and whether his disorder is considered to be educationally handicapping.

Submitting the Claim Properly

Submitting the health insurance claim properly can help prevent a rejection. It’s important to submit the paperwork on time; some insurance companies have strict deadlines. Provide all information requested on the claim form. Ask the speech therapist which diagnostic code he is using and whether it indicates a developmental disorder. These codes are typically in the 315’s. Request a different code, if possible.

Read the form thoroughly and make a note of all requested supporting documents. Some commonly requested supporting documents include:

• Physician referrals
• Written results of the initial evaluation
• Treatment plan
• Speech therapist’s statement proving medical necessity
• Progress reports (if your child is already undergoing treatment)

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