Autism & Special Needs Insurance Intake
Within TDLC you will find a team of dedicated and supportive insurance and medical billing professionals, with years of experience managing healthcare insurance billing, contracting, authorizations/pre-certifications and denial rebuttals.
New insurance laws and mandates in Texas can be difficult to understand in regards to the benefits and eligibility for Applied Behavioral Analysis (ABA), speech therapy and occupational therapy. However, TDLC’s insurance experts are well versed in different plans of most major health insurance carriers. We are your advocate and are qualified to assist you because:
We know the right questions to ask in order to obtain the correct benefit information specific to ABA treatment and autism
We understand what is required by insurance agencies when it comes to authorizations and pre-certifications.
We will file all claims for you. We are specialized in billing ABA services to all managed care health plans. Your claims will be billed and processed correctly the first time.
All services from insurance verification, obtaining prior authorization, filing claims to your health insurance plans, follow up on your claims payments, and rebuttal of your claim denials are completed with our trusted partner MRC, which are AB! It will take 5-7 business days for MRC to return the benefits.
Autism Texas Mandate (Medicaid Buy-In)
What is the MEDICAID Buy-In Program?
In the past, Applied Behavioral Analysis (ABA) was not covered by most health insurance plans. However, with the ongoing proven success of ABA-based treatment for autism, the autism insurance mandate was established and passed. Although the autism mandate varies from state to state, specifically, the State of Texas mandate for autism requires health benefit plans to provide coverage to an enrollee who diagnosed with autism spectrum disorder (ASD) from the date of diagnosis until the enrollee completes nine years of age, for all generally recognized services including ABA, speech therapy, occupational therapy, and/or physical therapy prescribed in relation to ASD by the child’s primary care physician in a treatment plan recognized by that physician.
Just because the State of Texas has an autism mandate, it does not mean all health insurance plans are required to include the coverage and benefits for the autism diagnosis. Please note that the autism mandate is applicable to the fully-funded, state-regulated plans only. If your health insurance plan is through your employer and is a self-funded plan, it does not legally have to offer the autism benefits. Self-funded plans are generally paid for by the employers and are governed by the federal government. The employers can decide which health benefits they want to provide. Although some self-funded health insurance plans cover the Applied Behavioral Analysis (ABA) therapy, there is no requirement by the federal government that requires them to do so.
Family of up to 3
Up to $4,633.00
Family of up to 6
Up to $4,633.00
The most a family will pay is $230.00 each month
Where to Get More Information
- Visit https://hhs.texas.gov
- Type "Medicaid Buy In for Children" in the search bar
- Call 2-1-1 or 1-877-541-7905
- Ask to have a FORM H1200-MBIC mailed to you
- Find an HHS office near you
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.
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 most current PCP information as it’s critical when receiving referrals and authorizations.
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.
If insurance covers services, how much will I pay?
Unfortunately, we cannot determine how much you will have to pay until after we bill to insurance for dates of service.
What is the required documentation for obtaining coverage?
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.
- A copy of the front and back of your 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.
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.
What is the difference between calendar year and fiscal year insurance?
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.
How do I know how much is covered by primary and secondary insurance?
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.
How does TDLC's billing cycle work? Are there payment plans?
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.
How do I know when to pay my copay / 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.
How can I switch my child's current services over 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.