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 Extraordinary Kids.
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
- AHCCCS
- Blue Cross Blue Shield (BCBS)
Out-of-Network Insurances
- Aetna
- Ambetter
- Cigna
- Humana
- UnitedHealthcare
- Private Pay
ESA Application Link
We are an approved vendor through the Arizona Empowerment Scholarship (ESA). ESA funds may be used to pay for therapeutic services for qualified students with disabilities. The ESA is available. Through the Arizona Department of Education. Click here for more information on applying for an ESA.
In-Network Insurances
- Tricare
- AHCCCS
- Blue Cross Blue Shield (BCBS)
Out-of-Network Insurances
- Aetna
- Ambetter
- Cigna
- Humana
- UnitedHealthcare
- Private Pay
ESA Application Link
We are an approved vendor through the Arizona Empowerment Scholarship (ESA). ESA funds may be used to pay for therapeutic services for qualified students with disabilities. The ESA is available. Through the Arizona Department of Education. Click here for more information on applying for an ESA.
Have an In-Network Plan?
Have an Out-of-Network Plan?
Have a General Question?
In-Network Insurance
Frequently Asked Questions
The best thing to do is contact your insurance company, and give them the following information/ask them the following questions:
- Let them know: my child will be receiving (speech and/or OT) from an in-network provider.
- Ask: What is my coverage for this service? Will I have a co-pay or co-insurance per visit?
- 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?
- Ask: Does my child need prior authorization in order to receive coverage?
- If yes, will the evaluation be eligible for coverage, or do I have to receive the prior authorization before I can get an evaluation?
- If no, is there a cap on how many visits my child can receive in a year, or how many visits my child can receive before a prior authorization is required
- Ask: Do I have to meet the plan's deductible before I receive any coverage?
- If yes, how much is my deductible, and how much of it have I met this year?
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, Extraordinary Kids will request the prior authorization.
During the intake process, we will ask for a credit card to be kept on file for co-payments and other applicable charges.
If you have BCBS, Tricare, or AHCCCS, your insurance company will be billed for our services first. Upon insurance completion of claim processing, payment for any uncovered services, patient responsible fees (co-pays, co-insurance, deductible) and cancellation/no show/late fees will be charged on the card on file.
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. 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 would prefer to make your payment using a payment method other than the card of file, please let us know at the time of treatment. We accept cash, check, debit, and all major credit cards for payment.
If you are ever in need of a coded invoice, just let us know and our medical biller will send you one.
This will depend on your insurance company. In general, Extraordinary Kids handles all reauthorizations for in-network insurance clients and will contact you only if you need to have your Primary Care Manager renew the authorization. Otherwise, the client does not need to worry about this.
Because different insurances and plans vary, we recommend you call your insurance company to verify benefits and limitations in coverage.
Out-of-Network Insurance
Frequently Asked Questions
This will depend on your insurance company. In general, Extraordinary Kids 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.
A Private Pay client is responsible for all services received at Extraordinary Kids. 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 Extraordinary Kids.
During the intake process, we will ask for a credit card to be kept on file for co-payments and other applicable charges.
For Out-of-Network or Private Pay clients, payment is due, in full, at the time of service. A superbill will be provided upon the client’s request.
If you would prefer to make your payment using a payment method other than the card of file, please let us know at the time of treatment. We accept cash, check, debit, and all major credit cards for payment.
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:
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- My child will be receiving (speech and/or OT) 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)
- Are there any diagnosis/condition limitations that would disqualify my child from receiving benefits, such as no coverage for developmental delays?
- Does my child need prior authorization in order to receive the above benefits?
- If yes, will the evaluation be eligible for reimbursement or do I have to receive the prior authorization before I can get an evaluation?
- 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?
- 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?
- 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 a one-hour OT session, while others will only pay up to a maximum dollar amount (such as $90 for a session)).
- What is your Eligible Charge/Fee Schedule for the following treatment codes:
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- 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)
- 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 Re-education, 15 minutes) 97110 (Therapeutic Exercises, 15 minutes), 97535 (self-care and activities of daily living training, 15 minutes)
Extraordinary Kids 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.
Extraordinary Kids will submit claims to your insurance company on your behalf. If you qualify for reimbursement, it will be sent directly to you, not to Extraordinary Kids. Keep in mind, you will be charged directly by Extraordinary Kids for any services rendered, whether or not your insurance reimburses you. Extraordinary Kids 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.
Arizona ESA
Frequently Asked Questions
The Arizona ESA (Arizona Empowerment Scholarship Account) is a state-funded program providing parents funds to customize their child's education.
Among other educational costs, AZ ESA funds may be used to pay for specialized therapies, including Speech and Occupational therapy.
The ESA is available through the Arizona Department of Education. Click here for more information on applying for an ESA.
There are two ways to pay using ESA:
- ESA Debit Card: You can use your ESA provided debit card to pay at the time of treatment.
- Reimbursement: Pay at the time of treatment and then submit your receipt and through the ESA portal to get reimbursed, similar to Private Pay.
General FAQ
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, Extraordinary Kids’ charge may be higher than the insurance’s eligible charge, so your benefits will be based on the eligible charge, not the number that Extraordinary Kids charges for a service.)
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.
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!
Contact Us! Our medical biller will be happy to help!