BS!! If you have a diagnosis then the insurance company has to cover any therapy your son needs. We went through the song and dance with the insurance company. They were very obstructive. You have to keep on them. Answers will vary depending on who you get on the phone.

Our IEP is scheduled for 11/26. we have been on a list since last year. that is their reason for denying ABA therapy. I called and got a case number today for a case manager to be assigned to me and was given a 48 hour tunaround promise. Keeping fingers crossed.

We used to have UMR. You need to call them and tell them you want a case manager. Ours was very helpful getting these types of things untangled.

Speech therapy often bills out under ICD10 code F82.4. This code is used for educational purpose and not covered by private insurers. If you have a ASD/PPD-NOS diagnoses. And your UMR benefit plan covers ABA THERAPY (dictated as “Medically necessary”) your ST can bill with code, F84.0 (ASD/PPD-NOS ICD10 Billing code).

You should check your benefit plan outline to see if these services require preauth to be sent in by your physician prior to services rendered.

Unfortunately, this is the information I found reading through my wife’s UMR benefit plan, our daughter is under. UMR is the payer for UHC choice plus plans and other plans. It’s typically (from what I’ve found), self funded by your employer. If your employer has not elected for the ABA/ASD COVERAGE. Autism speaks actually has some decent resources to help paint a picture of the beneficiary for ST/ABA therapy.
We’ve received a request from UMR to get a second opinion on my daughters ASD diagnosis.

There are two levels of appeals with the insurance company. What you need to do is 1) get proof of medical necessity from the doctor 2) get the therapy plan that was proposed 3) write up the appeal where you personalize your child (make him/her a real person) and describe the need for the therapy.

you have to do two appeals before you go to the medical review board (which is like a Jury of lay people ). Those appeals need to explain well what is going on for lay people to understand. I did appeal my son's physical therapy and had some success