Insurance companies are complicated and all plans are different.  This information is intended to give you a good idea of how to find out what benefits are available to you in your health care plan.  Before you begin OT it is a good idea to ask your insurance carrier the following questions regarding you OT benefits. 

We have added a new section:  Understanding Insurance Terms 

1. Does my plan cover OT from an “out-of-network” provider?

Amy Zier & Associates, Inc. does not participate in any health insurance plans and therefore any services rendered through us are considered “out-of-network” for your insurance. 

If no, what percentage will they pay for out-of-network services? 

2. Is there a cap on OT benefits, monetary or number-of-sessions?

A monetary cap on OT benefits refers to the maximum dollar amount per year that your insurance plan covers.  The number-of-sessions cap refers to the maximum number of individual sessions that your insurance will cover within the fiscal year.   

3. Is an OT evaluation covered as part of my OT benefits?   Is it covered with an out-of-network provider?

Some insurance companies will cover OT individual sessions but they do not cover the initial evaluation, or they will cover the evaluation but you need further documentation and more review to cover individual sessions.  

4. What do I need to provide the insurance company in order to take advantage of the OT benefit?

Insurance companies often require a prescription for OT either from a physician, pediatrician, or other medical doctor.  A letter of medical necessity written by the occupational therapist and signed by a physician, pediatrician, or other medical doctor works much like a prescription.  Also, some insurance companies may  request the name, and state license number of the OT providing services.  Sometimes, not too often, the insurance company may also request copies of all medical records referring to the written evaluation report and daily treatment summaries.  

5. What percentage of OT is covered by my insurance with an out-of-network provider?

Insurance companies generally cover between 60-90% of the OT services provided by Amy Zier & Associates, Inc.   

6. What is my out-of-pocket max and what happens when I reach that dollar amount? 

Most health plans have an out-of-pocket max per year and per person on the policy.  This refers to the total dollar amount that the insured is responsible for per year regarding covered services.  If your child’s out-of-pocket max is $5,000 and you reach that dollar amount by receiving services covered through your health plan by paying co-pays, “patient responsibility”, etc., the insurance company will either cover services at 100% or have some other alternative when that $5,000 mark is met. 

Understanding Insurance Terms 

In Network Provider – Provider who is in (the insurance company's) network, in cahoots, with the insurance company.  Provider agrees to acceptable dollar amount per unit.  Provider agrees not to collect difference from family.  Insurance company tells clients about In Network Provider.  Insurance company controls provider.   

Out of Network Provider (AZ&A) – Insurance Company does not have an agreement with the provider. The provider does not have to do what insurance company says.  Provider does not have to satisfy the insurance company so it can focus on the customer.  

Explanation of Benefits (EOB) – The explanation sent to insured and provider along with any payment describing the services charged, amount allowed, and payment amount.  This explanation also includes reasons why coverage is not given, deductible remaining, etc…

Usual and Customary - The dollar amount that the insurance considers the norm, per unit, for the surrounding/local area. 

Allowable Amount – Amount, per unit, that the insurance will allow for coverage.  

Deductible – Amount for which the insured is responsible to receive coverage.

Co-Pay/Co-Insurance – Insured responsibility after deductible is paid.  Co-Pay/Co-Insurance generally runs between 60-90%.

 Out-of-Pocket-Max – The total dollar amount for which the insured is responsible per year for covered services.  Each insured member of plan has an out of pocket max. 

Monetary Cap on Services – The maximum dollar amount that insurance will pay per year for specific services.

 Number-of-Sessions Cap - The maximum number of sessions that allowed by insurance within the fiscal year.  Insurance will not allow coverage for any treatment session after the Number-of-Sessions Cap has been met.  This does not mean services need to cease, however family is responsible for 100% of the cost. 

 Appeal – Process of appealing the judgment regarding services.  Used to get higher Monetary Cap on Services, and or Number-of-Sessions Cap.