Orange-BoxGuidance for Filing for Reimbursement through Insurance Out-of-Network Benefits*

  • Initiate Prior Authorization
    Contact your insurance company member services department.

The phone number is generally located on the reverse of your insurance card. Your insurance company may require prior authorization before allowing a claim for out-of-network services. This process is carried out by you. If you need information from our office about your appointment, contact our Business Manager at Square One as soon as possible for assistance in the prior authorization process. (Please note that acquiring authorization does not guarantee reimbursement from your insurance company for your payment for our services.)

In addition, your insurance company may require a referral from your in-network provider before allowing claims for these services. In this case, contact your child’s primary care pediatrician to initiate the referral process.

You may need procedure codes (CPT codes) in the prior authorization process, as well. CPT codes for services provided at Square One include:

  • 90791 Psychiatric Diagnostic Interview (Psychologist, Dr. Causey)
  • 90792 Psychiatric Diagnostic Interview with Medical Services (Psychiatrist)
  • 99245 Medical Evaluation Initial
  • 99204 Medical Counseling New Patient
  • 96101 Psychological Testing
  • 90887 Psychological Counseling
  • 90837 Individual Psychotherapy Therapy, 60 mins
  • 90846 Family Psychotherapy without Patient
  • 90847 Family Psychotherapy Conjoint with Patient
  • 99214 Medical Counseling Established Patient (Psychiatrist)
  • 99215 Medication Check (Developmental Pediatrician, Dr. Axelrod)
  • 99244 Medical Evaluation Follow Up (Developmental Pediatrician, Dr. Axelrod)
  • 92506 Speech-Language Evaluation
  • 92507 Speech-Language Therapy
  • 92508 Group Pragmatic Speech Therapy (Social Speech-Language Skills)
  • File your claim right away.
    Contact your insurance company member services to receive their claim form or a HCFA 1500 for filing for reimbursement through your out-of-network benefits.

This form may even be available to you through your member account on their website. Some insurance companies will not allow claims beyond a certain time after the date of service (usually 90 days). As noted above, at every appointment for services, we will provide you with an itemized statement detailing diagnosis codes (ICD) and procedure codes (CPT) as support in this process.

You will need to complete your claim form with the information provided on our itemized statements. If the forms require the doctors’ signatures, our office manager will review the information that you have completed on the claim form and arrange for the signatures. These will not be available immediately.

You may pick up the signed claim forms within a few days or leave a self addressed stamped envelope if you would like for us to put it in the mail for you. We recommend keeping a copy of the signed claim form for your records. Square One does not retain any information related to insurance claims.

We will provide any additional information or supporting documentation at your request. We will require an authorization for release of information on file in this case.

  • Please note, for best results:

Services provided by Behavioral-Developmental Pediatrician Dr. Axelrod will likely need to be filed through your medical out-of-network benefits.

Services provided by the Psychologists Dr. Causey and Dr. Ruble, Licensed Clinical Psychologist Associates Ann Ronald and Todd Johnson, or Licensed Clinical Social Worker Sherri Stover will likely be filed through your mental health out-of-network benefits. Information from the American Psychological Association regarding mental healthcare benefits: http://www.apa.org/helpcenter/parity-guide.aspx

Services provided by our Speech-language Pathologist Ashley Redenbaugh may be filed through “other medically necessary services” benefits. Please refer to the American Speech Hearing Association for guidance: http://www.asha.org/public/coverage/php.htm

  • Keep track of your authorized sessions
    Once sessions for services are authorized, this means that a claim will be allowed for filing, but does not guarantee reimbursement. Sometimes insurance companies approve a certain amount of sessions over an allotted period of time, and will likely not reimburse for services provided outside of this frequency in the specified time frame. It may be necessary to initiate multiple prior authorizations for allowable claims throughout your child’s treatment at Square One.

*Please note that our office will provide you the information your insurance company requires for your claim filing. Many of our families tell us that they have had success by following the above methods. However, Square One cannot file the claims for you and cannot guarantee that the above tips will lead to reimbursement for your payment for our services.  Claim filing varies with each insurance company, so company specific forms are not available at our office.