Funding Speech Services. Understanding Benefits and Eligibility for Speech Therapy Services
At Speech in the City, we take the stress out of understanding your insurance benefits. Our team verifies your benefits, helps determine your eligibility for speech therapy services, and submits claims on your behalf whenever possible. While we handle the insurance process for our families, we believe it’s still helpful to understand how your coverage works and what your benefits mean.
Navigating insurance can feel overwhelming, especially if your Speech-Language Pathologist is out of network. Fortunately, understanding a few key terms can help you better understand your financial responsibility and maximize your benefits.
How Insurance Coverage for Speech Therapy Works
Step 1: Understanding ICD-10 and CPT Codes
Insurance companies use two different types of codes when determining coverage.
ICD-10 Diagnosis Code
The ICD-10 code explains why speech therapy is medically necessary. Your Speech-Language Pathologist or physician can provide this code.
Examples include:
- Autism Spectrum Disorder: F84.0
- Mixed Receptive-Expressive Language Disorder: F80.2
CPT Procedure Code
The CPT code identifies what service was provided during the therapy session.
For example:
- 92526 – Treatment of swallowing dysfunction and/or oral function for feeding
Together, these codes tell your insurance company why therapy is needed and what treatment was performed.
Step 2: Understanding Your Insurance Benefits
At Speech in the City, we verify these benefits for our families before services begin whenever possible. We review your policy to determine:
- Your out-of-network deductible and how much has already been met
- Your out-of-pocket maximum
- Your reimbursement percentage after meeting your deductible
- Whether speech therapy requires preauthorization
- The number of speech therapy visits covered each year
- Whether speech therapy visits are combined with occupational or physical therapy benefits
- Any visit limits or exclusions that may affect your coverage
Understanding these benefits allows families to make informed decisions before beginning therapy.
Step 3: Claims and Reimbursement
Our office assists families with the insurance process by submitting claims on your behalf whenever possible and providing all necessary documentation for reimbursement.
Insurance claims typically include:
- Date of service
- Place of service (office, home, school, or teletherapy)
- CPT procedure code
- ICD-10 diagnosis code
- Provider’s National Provider Identifier (NPI)
- Provider license information
- Amount charged for services
Although every insurance plan is different, many families with out-of-network benefits receive reimbursement for a portion of their therapy costs after meeting their deductible.
Frequently Asked Questions
What does an in or out-of-network deductible mean?
Your deductible is the amount you must pay before your insurance company begins reimbursing eligible services. For example, if your plan has a $1,000 deductible with 70% out-of-network coverage, you would first pay the $1,000 deductible. After that, your insurance may reimburse approximately 70% of the allowed amount, leaving you responsible for the remaining portion.
Will insurance cover all speech therapy sessions?
Coverage varies by plan. Some policies provide unlimited medically necessary speech therapy, while others limit the number of visits each year. Certain plans also combine speech, occupational, and physical therapy into a shared annual visit limit.
Do I have to call my insurance company?
In most cases, no. Our administrative team verifies your benefits and helps guide you through the insurance process. If additional information is needed from your insurance carrier, we’ll let you know exactly what to ask.
We’re Here to Help
Understanding insurance shouldn’t prevent your child from receiving the care they need. Our team is committed to making the process as simple as possible by verifying benefits, helping families understand their coverage, and assisting with claims so you can focus on what matters most—your child’s progress.