Is an autism diagnosis retroactive for insurance purposes?

[Anonymous]

I am trying to figure out how to get our insurer to pay for some OT and speech therapy that is theoretically covered by our insurance plan. They have been rejecting claims and I am working with them to figure out why. One issue is an administrative one (getting prior authorization, putting the right codes on the superbills). I am not sure if another possible issue may be that we started these services prior to getting the diagnosis. We are still waiting for the report from the assessment but the evaluator has told us verbally about the diagnosis and recommended we keep these services. If the diagnosis is an issue for getting these services covered, when would it take effect? After we get the report? When the providers put it on the superbill? Can it be retroactive (she's obviously always had autism)?

[Anonymous]

Unlikely. When you got there therapy service, you should have been getting the insurable diagnosis at the same time.

[Anonymous]

Anonymous wrote:Unlikely. When you got there therapy service, you should have been getting the insurable diagnosis at the same time.

Thanks, but I genuinely have no idea what this means. OTs and SLPs do not diagnose autism.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Unlikely. When you got there therapy service, you should have been getting the insurable diagnosis at the same time.

Thanks, but I genuinely have no idea what this means. OTs and SLPs do not diagnose autism.

What dx code did the therapists use when submitting to insurance? Has your insurance told you that the service would be covered if billed under autism?

Since as you say she was always autistic, I would ask the service providers to resubmit using F84.0.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Unlikely. When you got there therapy service, you should have been getting the insurable diagnosis at the same time.

Thanks, but I genuinely have no idea what this means. OTs and SLPs do not diagnose autism.

Which is why you should have gotten a diagnosis before starting OT and SLP services, if you wanted reimbursement.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Unlikely. When you got there therapy service, you should have been getting the insurable diagnosis at the same time.

Thanks, but I genuinely have no idea what this means. OTs and SLPs do not diagnose autism.

What dx code did the therapists use when submitting to insurance? Has your insurance told you that the service would be covered if billed under autism?

Since as you say she was always autistic, I would ask the service providers to resubmit using F84.0.

Of course not. That would require them to want to help me get my claims approved.

They didn't tell me I needed prior authorization until I called about why claims were denied. They also didn't tell me the superbills didn't have the right codes on them - a provider noticed that. Now, we have to wait 15 days for the prior authorizations to go through (assuming they admit that they received them, which they haven't yet). Then we will find out if they approved the prior authorizations, and see if they approve the claims with the new codes. I asked about the diagnosis but they did not provide any answer for me.

Each phone call requires spending a minimum of 20 minutes on hold. I am losing patience and we are only getting started.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Unlikely. When you got there therapy service, you should have been getting the insurable diagnosis at the same time.

Thanks, but I genuinely have no idea what this means. OTs and SLPs do not diagnose autism.

Which is why you should have gotten a diagnosis before starting OT and SLP services, if you wanted reimbursement.

My goodness, I do apologize for wanting to help my child!

I'm not sure if you actually think you're being helpful, but fyi, you are not.

[Anonymous]

The answer is likely to depend, not on the diagnosis, but on your insurance company's policy.

[Anonymous]

It depends on your insurance but probably not. You were right to start services before a diagnosis.

[Anonymous]

The answer is no, health insurance would never do anything helpful like that

[Anonymous]

Thanks. It is helpful to know it is not a thing to make the diagnosis retroactive. Can I ask the providers to add the diagnosis code now that I know it or do I need to send them the official report (which I do not have yet?)?

[Anonymous]

It’s effective from the time that the report is finalized. For good measure, I’d have the report uploaded to the medical chart wherever you’re getting OT and ST. They can add the diagnosis to all his progress notes too to prevent any further insurance confusion.

[Anonymous]

To clarify they can upload the report under the media tab of Epic (assuming that’s what they use). It doesn’t matter if the report is from an outside provider or private pay doc they can still upload it.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Unlikely. When you got there therapy service, you should have been getting the insurable diagnosis at the same time.

Thanks, but I genuinely have no idea what this means. OTs and SLPs do not diagnose autism.

Which is why you should have gotten a diagnosis before starting OT and SLP services, if you wanted reimbursement.

Given that diagnoses are often unstable for very young kids, and that diagnosticians have months or years long waiting lists this is absurd.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Unlikely. When you got there therapy service, you should have been getting the insurable diagnosis at the same time.

Thanks, but I genuinely have no idea what this means. OTs and SLPs do not diagnose autism.

Which is why you should have gotten a diagnosis before starting OT and SLP services, if you wanted reimbursement.

That’s some bad advice. Especially Autism in girls.