Insurance & Billing Information

The best thing to do is contact your insurance company, and give them the following information/ask them the following questions:

1) Let them know: my child will be receiving (speech, OT, PT) from an in-network provider. 

2) Ask: What is my coverage for this service? Will I have a copay or coinsurance per visit? 

3) Ask: Are there any diagnosis/condition limitations that would disqualify my child from receiving benefits, such as no coverage for developmental delays, or specific benefits for an Autism Diagnosis.

4) Ask: Does my child need a prior authorization in order to receive coverage? 

a) If yes, will the evaluation be eligible for coverage, or do I have to receive the prior authorization before I can get an evaluation? 

b) If no, is there a cap of how many visits my child can receive in a year, or how many visits can my child receive before a prior authorization is required? 

5) Ask: Do I have to meet the plan deductible before I receive any coverage?

a) If yes, how much is my deductible and how much of it have I met this year?

Our pricing information is provided in our new client paperwork. If you need pricing information before filling out your new client paperwork, send us an email or give us a call!

Deductible – This is the amount of money you pay out-of-pocket in a year before your insurance starts paying for your healthcare expenses. After you meet your deductible, you will only need to pay your co-pay or your coinsurance, depending on your policy. (Some insurance plans don’t require you to meet your deductible before paying for therapy services)

Co-Pay – This is the fixed amount of money you pay per visit (after you’ve met your deductible when applicable).

Coinsurance – This is the percent of the total cost of a session you pay (after you’ve met your deductible when applicable).

Pre-authorization – This is a restriction placed on certain health services by your insurance company that requires your therapist to be granted permission before your plan will cover that service. (Obtaining this doesn’t guarantee that you will receive coverage for this service.)

Referral – This is a written order from your primary healthcare provider for you to receive specialized medical services. Most insurance plans require one to cover therapy services.

Eligible Charge – The maximum amount an insurance plan will pay for a covered health care service. May also be called “allowed amount,” “payment allowance,” or “negotiated rate.” (Private Pay Clients please note, Sprouts’ charge may be higher than the insurance’s eligible charge, so your benefits will be based on the eligible charge, not the number that Sprouts Therapy charges for a service.)

Not a problem! If you need a doctor’s referral, your physician can provide a provisional diagnosis (when the clinician thinks a particular disorder/delay is present but realizes more information is required to be confident of a specific diagnosis). Upon evaluation, the therapist(s) will assess your child’s skills and provide a treating diagnosis if applicable.