We understand healthcare billing can be challenging, which is why we do our best to make the process as stress-free as possible. We accept all major private insurance plans and would be happy to verify your insurance benefits prior to treatment. To review which insurance carriers we are in-network with by clinic, please review below. To start this process, you will need to complete our intake paperwork which you can do by clicking here.
Our billing team is here to answer any questions you have and explain our claim procedures, so you can keep your focus on your child without missing a beat. If you have any questions about your insurance coverage or billing claims, schedule a call with a member of our billing team below.
How do I know if my insurance plan is accepted?
If you're interested in services at any of our clinics, the first step is to complete our intake paperwork
, which will allow us to verify your insurance benefits and determine coverage for services.
What forms of payments are accepted?
- Credit Card (Visa, Mastercard, Amex)
- Bank or Wire Transfer
How do you determine coverage?
We verify your coverage with your insurance company before your treatment begins. Please note: When we verify your insurance coverage, it is only a quote, not a guarantee that your provider will pay. We encourage you to call your insurance company to determine the exact benefits your plan provides. If you are asked, tell your insurance carrier that NAPA location or clinic is classified as “service place 11” which indicates we are in an office setting. To assure the highest level of coverage, please review any possible limitations and requirements your insurance plan might have.
What requirements does my insurance plan require?
- You will need to check with your insurance company directly to determine the specifics of your plan, but here are a few common requirements of insurance plans:
- Co-pay by the patient at the time of service
- Referrals from primary care physician (PCP) at the initial visit
- Limits for therapy visits each calendar year
- Pre-certifications/Prior Authorization
- Deductible and co-insurance obligations
- Sometimes insurance payments may be delayed, reduced or denied. If this happens, and we are out of network, you will be required to pay the unpaid balance. If we are in-network we may ask for your assistance to help remedy any issue.
My insurance provider is not on your list. What happens next?
If your carrier is NOT on the list, you can utilize your out of network benefits or you can self-pay and potentially seek reimbursement with a superbill.
What is the difference between in and out of network coverage?
In-Network – NAPA has a contract with these carriers at this location, which makes an accurate estimate much easier since the rates are set.
Out-Of-Network – NAPA does not have a contract with this carrier. Some health plans, like HMOs, will not cover care from out-of-network providers at all. Generally, if your insurance is out-of-network, your share of cost, including your deductible & copay or coinsurance, will be higher for out-of-network services.
Why is it difficult to estimate out of network coverage?
All insurance companies & plans are unique regarding reimbursements. If insurance determines the "Usual & Customary Rate" to belower than our rate, they will only cover a portion of it. For example – if your out-of-network coinsurance is 70/30, it would be reasonable to assume thatfor a $165 service, your insurance would pay would be $115.50 (70% of $165.) However, if the out-of-network carrier says the “Usual and Customary” rate is $90 then they will pay their portion of that rate which would be $63 (70% of $90)and you would be responsible for the remainder up to the full billed rate of $102 per session.
Unfortunately, there is no standardized “Usual and Customary Rate” in the industry. It varies for every insurance plan.
We won’t get this information until after the claim processes and this can change at any time. Therefore, it is difficult to determine the total. So generally, we will base the estimateoff of previous claims, if you have been to us before. If not, then we will base your share of cost on the total billed amount, but you may end up with a credit or balance once your session is complete. At which point you will receive that information in your monthly statement.
Why are you not in network with mycarrier?
Each clinic must contract individually with carriers, and each state and carrier vary significantly. With our unique intensive model, it makes it even more complicated when it comes to contracts and insurance policies. For us to keep up with our training program, 50-minute appointments, and exceptional level of care, we must make tough decisions as to how to sustain this in the current insurance market.
What other options are there for Out-of-Network families?
We offer competitive self-pay rates that are potentially less expensive than having to pay out-of-pocket deductibles, copays, and coinsurance.
If you choose to self-pay, you can also submit a superbill to your insurance after the session is completed, to try to get reimbursed. To make sure we bill appropriately so the superbill is usable; let us know prior to your session that you will need a superbill. If requested prior to the session, the superbill will be sent electronically after the session.
My NAPA clinic doesn’t take Medicaid even for secondary. Why not?
State Medicaid is all or nothing. To accept Medicaid as secondary, we would need to accept it for primary as well. Unfortunately, each state has vastly different rules and regulations regarding Medicaid. Once you are a Medicaid provider the rules must apply to all patients at that facility. In some states, we would not be able to offer multiple hours of therapy per day if we were Medicaid providers. If the clinic does accept Medicaid, they will only accept their state’s Medicaid. For this reason, no clinic accepts out-of-state Medicaid.
Visit limits explained
When planning your intensive, make sure you are aware of your visit limits. Some plans are unlimited but some have a max number of visits allowed per year.
There are two types of limits:
- Hard Max: this is a set limit ex 50 per year. You cannot appeal or request more visits once this is exhausted.
- Soft Max: this is a soft limit. You can apply for more visits once yours are exhausted and most carriers will do a medical necessity review. There is no guarantee they will approve more visits.
Even if your insurance does not have a visit limit, insurance will still often only pay for 1 hour of each specialty per day, including physical, occupational, and speech therapy.
DIAGNOSIS SPECIFIC Limits: Some states have legislation for a specific diagnosis to offer unlimited visits regardless of your plan. This is typically only for Autism, but it is worth asking your carrier. If this is diagnosis-specific, you will need that specific diagnosis on your prescription if this is the case.
Out- of- Pocket Max: An out-of-pocket maximum is a cap, or limit, on the amount of money you have to pay for covered health care services in a plan year. If you meet that limit, your health plan will pay 100% of all covered health care costs for the rest of the plan year. Some health insurance plans call this an out-of-pocket limit. Please keep in mind though visit limits STILL apply. So if you are out of visits they still will not pay. Out of network carriers will only pay 100% of their reasonable and customary charge and families will be billed the difference. If your insurance will not cover more than 1 hour of each specialty per day, you will still be billed for the additional hour of any specialty even if you have hit your out-of-pocket max.
Prior Authorization: Some plans require prior authorization before they will cover visits. They will often require a copy of your evaluation and care plan and will determine how many visits they deem appropriate during a specific time frame. Sometimes we are unable to request the authorization until the intensive starts because they want a NAPA-specific care plan. Often this can cause delays since visits are done in such a short time frame.
When will I get my final invoice?
We provide a final invoice 60 days prior to your session start date. As you can imagine, many things change throughout the year. We book intensives the year prior, so we don’t know your plan details until the following year. In addition, we can’t account for things like your deductible, out-of-pocket max, and visits count until we are closer because those change throughout the year.
I have met my out-of-pocket max. Do I still have to place a deposit?
Your deposit serves to secure your spot for your scheduled session. It will be used towards any balance that you may have with your full invoice. If you’ve met your out-of-pocket max and/or insurance covers the full cost of your intensive, your deposit can remain on your account for future sessions or be refunded.