INSURANCE AND BILLING

Insurance and Billing

Insurance and Payment Information


We understand that insurance coverage for pediatric therapy services can be confusing and complicated. Don’t worry we have your back! We encourage you to read through our Q&A below for more information on your benefits with Sprouts Therapy.


The first step in understanding your insurance benefits is to find out if we are in-network or out-of-network with your insurance company:

In-Network Insurances

Tricare

CHAMPVA

Kaiser Permanente (HMO, Quest, Added Choice)

United Healthcare Commercial plans

UMR

DMBA

Aetna

CIGNA

AlohaCare (Medicaid) - OT and PT (2022)

Out-of-Network Insurances

HMSA

HMAA

UHA

AlohaCare (Medicaid)- Speech Therapy

Ohana

BCBS

United Healthcare Medicaid

Other

Have an In-Network Plan?

Have an Out-of-Network Plan?

Have a General Question?

In-Network Insurance

Frequently Asked Questions

  • How do I determine my in-network insurance benefits for therapy?

    The best thing to do is contact your insurance company, and give them the following information/ask them the following questions:

     

    1) Let them know: my child will be receiving (speech, OT, PT) from an in-network provider. 


    2) Ask: What is my coverage for this service? Will I have a copay or coinsurance per visit? 


    3) Ask: Are there any diagnosis/condition limitations that would disqualify my child from receiving benefits, such as no coverage for developmental delays, or specific benefits for an Autism Diagnosis.


    4) Ask: Does my child need a prior authorization in order to receive coverage? 

    a) If yes, will the evaluation be eligible for coverage, or do I have to receive the prior authorization before I can get an evaluation? 

    b) If no, is there a cap of how many visits my child can receive in a year, or how many visits can my child receive before a prior authorization is required? 


    5) Ask: Do I have to meet the plan deductible before I receive any coverage?

    a) If yes, how much is my deductible and how much of it have I met this year?

  • My insurance requires I have a prior authorization for treatment in order to receive coverage for services, how do I go about getting that?

    If your insurance requires a prior authorization before evaluation, then your child’s doctor will need to submit the request for the prior authorization. If your insurance requires prior authorization after initial evaluation, Sprouts Therapy will request the prior authorization.

  • How does billing work if I am an in-network insurance client?

    Sprouts Therapy will bill your insurance carrier upon services rendered. Upon insurance completion of claim processing, payment for any uncovered services, patient responsible fees (copays, co-insurance, deductible) and cancellation/no show/late fees will be charged on the card on file weekly (typically Mondays). Please keep in mind that insurance claims can take up to 30 days to process, and that we do not charge any applicable fees until the claim has fully processed. Any cancellation or late fees incurred the previous week will also be run on the card on file on Mondays. We do not send out weekly invoices, we run the card on file and you will receive a payment receipt that will detail what dates of service the charge was applied to. If you are ever in need of a coded invoice, just let us know and our medical biller will send you one.

  • What happens when my child’s insurance authorization expires or runs out of visits? How does reauthorization work at Sprouts Therapy?

    This will depend on your insurance company. In general, Sprouts Therapy handles all reauthorizations for in-network insurance clients, and will contact you only if you need to have your PCM renew the authorization. Otherwise, the client does not need to worry about this. Below is an explanation for Tricare Prime and Kaiser clients. 


    Tricare Prime: Most Tricare authorizations are good for a 6 month time period, at that point, Sprouts Therapy can apply for an additional 6 months if needed. Once it has been 12 months since the initial authorization was submitted, your child’s PCP will need to put in a request for a renewed authorization. Sprouts Therapy submits evaluations and progress reports to the Tricare Documentation System, which is accessible to your child’s PCP and assists with the renewal. 


    Kaiser: Most Kaiser authorizations can be renewed by Sprouts Therapy. Sprouts Therapy faxes a request for additional visits and/or a date extension, along with progress reports, evaluations, plan of care etc, which is then reviewed by the Kaiser Authorization department. The Kaiser auth department will then review the information and approve/deny further sessions. Sprouts Therapy monitors this process, and will notify you of any denials. On some rare occasions, the patient will have to return to their PCP to request additional sessions, if this scenario applies, Sprouts Therapy will contact you.

Do you have any information on specific insurance coverage that you can provide?

While we do 100% recommend you call your insurance company to verify, we do have some general information for a few insurance companies. Please do not take this verbatim, it is just to use as a reference.

Tricare Prime Clients

Before beginning services with us, you will need to obtain an authorization through Tricare/Healthnet for occupational, physical, and/or speech therapy services.  You will need to have a medical referral or prescription from your child's pediatrician sent to Tricare in order to obtain this. We will charge Tricare for services rendered. Typically, no shared cost if Sprouts Therapy is the servicing provider on authorization. (Exception being Retired Duty Members - those plans typically have a copay).

Tricare Select Clients

Before beginning services with us, we will need a doctor referral for services on file (no authorization required). We will charge Tricare for services rendered. Each session will have a coinsurance until deductible and annual out of pocket maximum is met. Typically Tricare select clients pay between $26-$45 per session in coinsurance after deductible is met, and once the out of pocket maximum is met for the year, the sessions are covered in full. However, keep in mind that in January your plan renews and your deductible and coinsurance will kick back in. 

Kaiser

Before beginning services with us, you will need to obtain an authorization for occupational, physical and/or speech therapy services. You will need to have a medical referral or prescription from your child's pediatrician sent to the Kaiser Auth department in order to obtain this. We will charge Kaiser for services rendered. Typically, the deductible does not apply to therapy services and most Kaiser HMO clients have a copay apply for each session. However, not all Kaiser plans are the same, so you will want to verify your deductible requirements and copay/coinsurance with Kaiser.

CIGNA/AETNA/UHC Commercial Plans

In most cases you will need to obtain a doctor’s referral for services. Therapy benefits vary widely for these three insurances. Please call your insurance plan directly for information on your specific plan benefits, our medical biller can also check in on this for you. Some therapy may require prior authorization. We will bill your insurance company for services rendered.

AlohaCare (Medicaid) (OT and PT)

Before scheduling an occupational or physical therapy evaluation with us, we will need a doctor referral on file. After the evaluation report and plan of care is completed, Sprouts Therapy will submit an authorization request to AlohaCare for treatment. AlohaCare must approve all treatment sessions at Sprouts Therapy. We will charge AlohaCare for services rendered. 

CHAMPVA Clients

Speech Therapy- CHAMPVA does not provide benefits for speech therapy without documentation from the state stating that the department of education cannot provide the recommended service for the child. 


Occupational/Physical Therapy- Before beginning services with us, we will need a doctor referral for services on file (no authorization required). We will charge CHAMPVA for services rendered. Yearly annual deductible must be met before benefits are provided. After deductible is met, each session will have a 25% coinsurance. Typically that is about $40 per session. 

Out-of-Network Insurance

Frequently Asked Questions

  • How do I determine if I am a Private Pay client?

    If you are not utilizing insurance, or we are not in-network with your insurance company, you are considered a Private Pay Client. 


    We are not in-network with HMSA, HMAA, UHA, Ohana, BCBS or UHC Medicaid. If you have one of these insurances, you will be a Private Pay Client. 


    (We are in-network with Tricare, UHC commercial plans, Aetna, CIGNA, Kaiser Permanente and AlohaCare (OT and PT). If you have one of these insurances you are considered an in-network insurance client, and this section is not for you). If you have any insurance other than what is listed above, you are most likely an out-of-network insurance client, but send us over your insurance information and we will double check for you!

  • What does it mean to be a Private Pay client?

    A Private Pay client is responsible for all services received at Sprouts Therapy. Because we are not in-network with your insurance company, we will not receive payment from your insurance company. If you have out-of-network benefits with your plan, those benefits will be reimbursed directly to you, not to Sprouts.

  • How does billing work if I am a Private Pay client?

    Your balance will be charged within 5 (business) days of the service date in order to qualify you for the prompt pay discount. (Most services rendered will be charged on the following Monday). If your card does not go through, we will contact you immediately for an updated card, as we cannot apply this discount to your service fee if we do not charge the fee within 5 business days of the service. Evaluation fees will be charged to the credit card on file upon report delivery (PDF via client portal). You will receive a payment receipt via email, that is also automatically filed in your client portal. (Please note the prompt pay discount does not apply to evaluation fees). Evaluations are charged once the report is completed and uploaded to your Therabill client portal for viewing/downloading (typically 2-4 weeks after evaluation date).

  • If I am a Private Pay client, how do I determine if I have out-of-network insurance benefits?

    Every insurance plan is different, so this is a tricky question to answer. The best thing to do is contact your insurance company, and ask them the following questions: 


    1) My child will be receiving (speech, OT, PT) from an out-of-network provider. Does my plan provide any reimbursement for this? (example: 60% of the eligible charge ​is reimbursable, 40% is patient responsibility + amount above the eligible charge​) 


    2) Are there any diagnosis/condition limitations that would disqualify my child from receiving benefits, such as no coverage for developmental delays? 


    3) Does my child need prior authorization in order to receive above benefits?

    a) If yes, will the evaluation be eligible for reimbursement or do I have to receive the prior authorization before I can get an evaluation? 

    b) If a prior authorization is not needed, is there a cap of how many visits my child can receive in a year, or how many visits can my child receive before a prior authorization is required?


    4) Do I have to meet the plan deductible before I receive any benefits, if so how high is my deductible and how much of it have I met this year? 


    5) Is there a max dollar amount or time amount my plan will pay for a certain service? (example: some plans will only pay for the equivalent of an hour OT/PT session, while others will only pay up to a maximum dollar amount (such as $90 for a session)). 


    6) What is your Eligible Charge/Fee Schedule​ for the following treatment codes: 

    a) Common Speech CPT Codes: 92523 (speech evaluation), 96210 (Feeding Evaluation), 92507 (speech and language treatment untimed), 92609 (only used if your child uses an AAC for communication, untimed), 92625 (feeding therapy, untimed) 

    b) Common OT CPT codes: 97167 (OT evaluation), 96125 (Standardized cognitive performance testing per hour, face to face time providing assessment, interpreting test results and preparing the report), 97530 (Therapeutic Activities, 15 minutes), 97112 (Neuromuscular Reeducation, 15 minutes) 97110 (Therapeutic Exercises, 15 minutes), 97535 (self care and activities of daily living training, 15 minutes)

    c) Common PT CPT codes: 97163 (PT evaluation),  97530 (Therapeutic Activities, 15 minutes), 97112 (Neuromuscular Reeducation, 15 minutes) 97110 (Therapeutic Exercises, 15 minutes), 97140 (manual therapy, 15 minutes), 97116 (gait training, 15 minutes) 

  • My insurance requires I have a prior authorization for treatment in order to receive reimbursement for services, how do I go about getting that?

    Sprouts Therapy will help apply for a prior authorization with your insurance if needed. Just let us know that your insurance company stated you need one, and we will have our medical biller assist in the request.

  • I obtained an out-of-network prior authorization approved for therapy, now what?

    Sprouts Therapy will submit claims to your insurance company on your behalf. If you qualify for reimbursement, it will be sent directly to you, not to Sprouts Therapy. Keep in mind, you will be charged directly by Sprouts Therapy for any services rendered, whether or not your insurance reimburses you. Sprouts Therapy is not responsible if your insurance denies the claim. Any disputes regarding reimbursement will be between you and your insurance company, although our medical biller will be happy to give you advice or answer questions you may have.

Do you have any information on specific insurances that you can provide?

While we do 100% recommend you call your insurance company to verify, we do have some general information for a few insurance companies. Please do not take this verbatim; it is just to use as a reference.

HMSA PPO

Typically allows the following for reimbursement per your policy benefits: 

  • 8 OT sessions/calendar year before a prior authorization is required.  
  • 1 PT session/entire duration of policy before a prior authorization is required.  
  • 1 SLP evaluation/calendar year before a prior authorization is required. 

Your benefit may or may not be applied to your deductible when applicable. HMSA does not provide benefits for therapy due to conditions related to developmental delay ("any significant lag in a child's physical, cognitive, behavioral, emotional, or social development, in comparison with norms".) However, if your child has an Autism diagnosis or if your plan has habilitative benefits, we may be able to secure additional OT, PT and/or SLP treatment sessions for reimbursement through prior authorization requests. 


Reimbursement rates vary by plan, however here is a rough estimate: Approximately $60-$140 for OT and PT Evaluations, and $130-$220 for SLP Evaluations. Approximately $80-$90 for OT/PT treatment sessions, and $60 for SLP treatment sessions. 

UHA

Typically allows reimbursement per your policy benefits for 8 OT/PT visits, and 1 SLP Evaluation directly to the subscriber. Prior authorization is required after that for any reimbursement. 

HMAA

OT and PT: No authorization required. Reimbursment percentage will depend on your specific plan benefits and deductible amount. Most HMAA clients get approximately $60-$70 back in reimbursment for OT/PT treatment sessions after annual deductible is met.


Speech: Requires prior authorization for evaluation and treatment sessions in order to receive reimbursment benefits. Your physician will have to put in auth request for a Speech Therapy Evaluation. Sprouts Therapy can request auth for Speech Therapy treatment after evaluation complete.


Please note: HMAA's eligible charge is lower than most other commercial insurances in Hawaii. Your reimbursment percentage will be based on HMAA's eligible charge, not on the amount you pay to Sprouts Therapy. 

HMSA HMO and Quest Plans

Typically do not have any benefits for out-of-network providers.

AlohaCare (Speech Therapy), Ohana and UHC Medicaid Plans

Typically do not have any benefits for out-of-network providers.


General FAQ

  • What does this Insurance Term Mean?

    Deductible – This is the amount of money you pay out-of-pocket in a year before your insurance starts paying for your healthcare expenses. After you meet your deductible, you will only need to pay your co-pay or your coinsurance, depending on your policy. (Some insurance plans don’t require you to meet your deductible before paying for therapy services)


    Co-Pay – This is the fixed amount of money you pay per visit (after you’ve met your deductible when applicable).


    Coinsurance – This is the percent of the total cost of a session you pay (after you’ve met your deductible when applicable).


    Pre-authorization – This is a restriction placed on certain health services by your insurance company that requires your therapist to be granted permission before your plan will cover that service. (Obtaining this doesn’t guarantee that you will receive coverage for this service.)


    Referral – This is a written order from your primary healthcare provider for you to receive specialized medical services. Most insurance plans require one to cover therapy services.


    Eligible Charge – The maximum amount an insurance plan will pay for a covered health care service. May also be called “allowed amount,” “payment allowance,” or “negotiated rate.” (Private Pay Clients please note, Sprouts’ charge may be higher than the insurance’s eligible charge, so your benefits will be based on the eligible charge, not the number that Sprouts Therapy charges for a service.)

  • What if my child doesn’t have a diagnosis?

    Not a problem! If you need a doctor’s referral, your physician can provide a provisional diagnosis (when the clinician thinks a particular disorder/delay is present but realizes more information is required to be confident of a specific diagnosis). Upon evaluation, the therapist(s) will assess your child’s skills and provide a treating diagnosis if applicable.

  • Why do you need a credit card on file?

    Sprouts Therapy processes payment for services rendered, non-insured services, copays/deductibles/coinsurance and/or cancelation fees on a weekly basis (typically Mondays). 


    Private Pay Clients: Your balance will be charged within 5 business days of the service date in order to qualify you for the prompt pay discount. (Services (and/or cancelations/no shows) rendered on Tuesday-Sunday will typically be charged on the following Monday). If your card does not go through, we will contact you immediately for an updated card, as we cannot apply the prompt pay discount to your service fee if we do not charge the fee within 5 business days of the service. Evaluation fees will be charged on the credit card on file upon report delivery (PDF via client portal). You will receive a payment receipt via email, that is also automatically filed in your client portal. (Please note the prompt pay discount does not apply to evaluation fees).  We do not send out weekly invoices, we run the card on file and you will receive a payment receipt that will detail what dates of service the charge was applied to. If you are ever in need of a coded invoice, just let us know and our medical biller will send you one. 


    In-Network Insurance Clients: Sprouts Therapy will bill your insurance carrier upon services rendered. Upon insurance completion of claim processing, payment for any uncovered services, patient responsible fees (copays, co-insurance, deductible) and cancelation/no show/late fees will be charged on the card on file weekly (typically Mondays). Please keep in mind that insurance claims can take up to 30 days to process, and that we do not charge any applicable fees until the claim has fully processed. Any cancellation or late fees incurred the previous week will also be run on the card on file on Mondays. We do not send out weekly invoices, we run the card on file and you will receive a payment receipt that will detail what dates of service the charge was applied to. If you are ever in need of a coded invoice, just let us know and our medical biller will send you one. 

  • How do I find out pricing information for private pay?

    Our pricing information is provided in our new client paperwork. If you need pricing information before filling out your new client paperwork, send us an email or give us a call!

  • What if I still have more questions?

    Contact Us! Our medical biller will be happy to help!

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