How to Learn Your Insurance Benefits for Occupational Therapy
Children at Play is an out-of-network provider for most insurance companies. These guidelines should help you learn & understand your insurance provider’s coverage for pediatric occupational therapy.
Call the phone number for members on the back of your insurance card.
Ask if you have out-of-network benefits.
If yes, ask if you have coverage for the CPT codes that may apply to you.
CPT codes commonly used for pediatric occupational therapy:
97530- Therapeutic Activities (MOST COMMON)
97110- Therapeutic Exercise
97535- Self-Care ADL's
971120 Neuromuscular Re-education
97116 Evaluation
97168- Re-evaluation
99368- Medical Team conference: (parent meetings, meeting with other providers, schools, etc).If you have coverage, you may want to also ask these questions:
If you need pre-certification. If yes, how it is obtained?
What is my deductible and has it been met this year?
What is my copay/coinsurance before and after my deductible is met?
How many sessions per calendar year does my plan cover?
What is the coverage amount for an out-of-network therapy session?
What documentation/information is required to submit for insurance reimbursement? Often you’ll need a “Superbill” which you can get from CAP’s patient portal.
Are telehealth sessions covered?
We have created a printable checklist to help you when you call your health insurance company. Click here to download a printable PDF.
Additional considerations:
Pediatric occupational therapy is rather specialized, and there aren’t many comparable providers in the area. Depending on your insurance, there may not be an acceptable in-network option for you, which means you could be eligible for a gap exception, also called an out-of-network exception or a network exception. It is more paperwork, but it is a way to access out-of-network care at in-network coverage. Here’s a helpful article to learn more.