Q: What is an EOB? How do I read it?
An EOB is an “Explanation of Benefits”. An EOB is an itemized statement from your insurance company. It contains the date of service, the code used to bill a particular service to an insurance company, the fee charged by the healthcare provider, the allowed amount under the third-party payer’s contractual fee schedule, the patient’s responsibility under the terms of their coverage, the payment made by the payer, and the contractual write-off. The final entry of each line item is usually titled something along the lines of, “what you owe,” or, “your responsibility.” This is why some patients confuse an EOB with a medical bill.
An EOB will also state rate changes. TDLC does NOT choose the rates you will be charged, unless you are a self-play client where insurance is not applicable.
Q: What is a script/referral? Will a letter of recommendation suffice in place of a script/referral?
A script/referral is similar to a prescription you would receive from your doctor when you go in for an illness. It is an order from your child’s primary care physician (PCP) stating your child needs ABA, ST, and/or OT services. The script must have the ICD-10 code for the diagnosis your child’s PCP is giving.
ICD-10 codes are utilized by insurance companies to properly note diseases on health records, track epidemiological trends, and assist in medical reimbursement decisions. ICD stands for International Classification of Diseases, and the 10 stands for the tenth edition of the clinical catalog. A letter of recommendation is not the same as a script and will not suffice for insurance verification purposes.
For example, if your child is diagnosed with Autism Spectrum Disorder, the physician must provide a script with the ICD-10 diagnosis code for Autism, in order to receive services (ABA, ST, and/or OT) through TDLC. Make sure to have the must current PCP information as it’s critical when receiving referrals and authorizations.
Q: What does prior authorization mean?
The approval by an insurer or other third-party payor of a health care service before the service is rendered. This approval is required in order for the insurer to pay the provider (TDLC) for the service.
Q: How will I know how much to pay if insurance covers services?
We cannot determine how much you will have to pay, until after we bill to insurance for dates of service.
Q: What is the required documentation for obtaining coverage and prior authorization for services?
In order to obtain prior authorization for services, we will need the following documentation:
- Script/referral from your PCP with current ICD-10 diagnosis codes to “evaluate and treat” for each therapy service you would like your child to receive.
- Detailed copy of the well child check up exam report (annual physical) from your PCP.
- Copy of front and back of insurance card.
- The Autism Spectrum Disorder (ASD) Diagnostic Report by a psychologist or a neurologist if your child requires treatment for an autistic condition.
***Because HMO network policies require a PCP’s involvement in prior authorization for services, we must have immediate notification from you whenever you change your child's PCP. It's really important that we have your child’s current & active PCP on file because we will constantly be needing referrals due to authorization periods.
Q: When does current documentation on file with TDLC expire? How far in advance do I need to supply this documentation?
Scripts/referrals expire every 6 months and the well child checkup expires after one year. Towards the end of every year, TDLC requires ALL current insurance clients to provide us with the above listed documents, no matter the type of policy you have, in order that we can expedite the process of re-verification of benefits without putting your child’s services on hold in the new year.
Q: Calendar vs. fiscal year insurance: how does it work?
If your insurance runs on a calendar year, it begins in January and ends in December. If your insurance company runs on a fiscal year, it is typically for a contract length of 12 months, starting at any given month. i.e. if your insurance begins March of 20XX, it will expire the last day of the month in February of 20XX.
Q: I have a primary and secondary insurance – how do I know how much is covered by each?
Insurance companies have rules and guidelines to determine which policy is the primary or secondary payor. However, it is your responsibility to inform both of your health insurance companies that you have two different policies and that you want to set up the coordination of benefits (COB). By doing this, both insurance plans can decide the level of responsibility, whether it will be primary or secondary insurance. TDLC, as a provider, does NOT determine which therapy service(s) will be picked up by the secondary insurance – it is only determined by the insurance company through COB.
Q: How does TDLC’s billing cycle work? Does TDLC provide payment plans for clients?
TDLC will email your billing statement on the 1st of every month. This will cover services rendered on the 25th of the previous month to the 24th of the current month. Your balance due date will be the 15th of every month. A Parent Handbook is also given to all clients before the scheduled start date to review further TDLC policies and procedures.
** For clients with a month to month retail policy through the exchange marketplace, TDLC requires that you provide proof of payment by the 15th of every month. If we do not receive proof of payment by the requested date, we will put your child’s services on hold until proof of payment is received. We strongly suggest that you decide on one marketplace plan throughout the year.
Q: How do I know when to pay my co-pay/patient responsibility?
It is determined by your insurance company that you pay at the time the service is rendered. You are required to pay per the designated due date, not by the date that insurance has processed your claims. However, TDLC chooses to bill you once a month for convenience.
Q: What if my child is already receiving services at another facility and has an open authorization for that specific treatment, but I want my child to go to TDLC
Please let us know as soon as you submit your application and we will provide you with a “Provider change request form” that you must complete and return as soon as possible. Once we receive the form, we will submit to insurance and request for the current authorization to be changes from your previous provider to TDLC. If the therapy service you are inquiring about require prior authorization the change of provider form must be done before we can schedule your child to start therapy at our facility.