Insurance Reimbursement Guide for Private Pay

Tumble N’ Dots is not an in-network provider with your insurance company. 

In some cases, the total cost of the evaluation and/or therapy sessions is reimbursed, however, benefits depend on your insurance coverage and other factors.

We will provide you with a superbill that includes all the insurance codes needed to seek reimbursement from your insurance carrier.

Since we do not bill your insurance for you or receive any reimbursement from your insurance carrier, payment in full is due regardless of any insurance claims.

In-Network vs Out-of-Network Coverage

When you visit a doctor or therapist within your insurance plan’s approved network, they’re considered an in-network provider. Out-of-network (OON) providers are those outside of your plan’s list.

Some insurance plans only cover in-network providers, while others offer coverage for both in-network and out-of-network services. 

A common misconception is that out-of-network services aren’t covered at all. In fact, many insurance plans reimburse 50-80% of out-of-network service costs once you’ve met your deductible. 

Understanding Out-of-Network Benefits:

  • Out-of-network means that we do not have a contract with your insurance company.
  • However, many insurance plans offer out-of-network benefits, which may cover a significant portion of the therapy costs.
  • It’s important to contact your insurance provider to understand your out-of-network coverage, including deductibles and reimbursement rates.

How to Check for Out-of-Network Coverage and Benefits

Call your insurance company. The customer line should be available on the back of your insurance card.

Ask the health insurance company representative the following questions:

  • Does my plan include out-of-network coverage for occupational therapy and/or speech therapy?
  • Do I have an annual deductible for out-of-network services?
    • If yes, what is the deductible?
    • How much of the out-of-network deductible was already met?
  • Is there a limit to the number of therapy sessions the plan will cover per year?
  • Is there a limit on out-of-pocket expenses per year?
  • What is the coinsurance percentage for therapy?
  • Do I need a referral for therapy services?
  • Can I submit a superbill for reimbursement? if so, how?

Provide with the following information if asked about the service provider:

  • Company Name: Tumble N’ Dots
  • Tax ID (EIN): 81-3640988
  • NPI Number: 1376045385
  • Taxonomy Codes:
    • 225X00000X – Occupational Therapist
    • 225XP0200X – Occupational Therapist – Pediatrics
    • 235Z00000X – Speech-Language Pathologist
    • 193200000X – Multi-Specialty Group
  • Address: 15265 Alton Parkway, #140, Irvine CA 92618
  • Phone Number: (949) 835-3746

Therapy Codes

The health care representative might ask for a CPT code (Clinical Procedure Terminology) for the therapy services.

Tips for a Smooth Reimbursement Process:

  • Your insurance might require you to have a physician referral/prescription, including a diagnosis. Please ask your child’s doctor to write a referral for OT, Speech, Feeding services, including your child’s diagnosis.
  • An insurance company will not consider coverage for a service that has not occurred. If you have been charged a non-service fee such as for late payment or late cancellation/no show, your account will reflect the payment, but your insurance will likely not reimburse for these charges.
  • Keep a dedicated folder for all your insurance documents and correspondence.
  • Be proactive in communicating with your insurance provider.
  • Ask Tumble N’ Dots for any additional documentation that may strengthen your claim. We are here to help!

Out-of-Network Exception

An out-of-network exception is a valuable option that can make accessing specialized care more affordable. You can request this exception from your insurance provider, which allows out-of-network services to be covered at in-network rates. Insurance companies may grant these exceptions in specific cases, such as when no in-network providers are available in your area or if the out-of-network provider has unique expertise not offered within the network. While the process may require a bit of effort to review your policy and communicate with your insurer, it can result in significant savings and ensure you receive the care your family needs.

FAQs

  • Will Tumble N' Dots complete a preauthorization form if required by my insurance company?

    Unfortunately, no. These forms typically ask questions about the diagnosis, recommended treatment, provider social security number, etc. This is either information we not know yet before we have started services or information we are unable to provide.

  • If my insurance company agrees to treat Tumble N' Dots as an in-network provider, can you bill them?

    Unfortunately, no. Each insurance company has different ways to submit claims and Tumble N' Dots can not determine what those are for each client. In network providers usually get more reimbursed, which is great, but we still can’t send in the bill for you.

  • What if my insurance will not reimburse for the whole amount charged by Tumble N' Dots?

    Most insurance companies will not cover the full rate. We do have some families that get the full reimbursement from their insurance company but your insurance may pay none, some, or all. You’ll need to work with your insurance providers and review your coverage benefits for out of network providers to determine what level you will be reimbursed.

  • Can the superbills be adjusted at the request of an insurance provider to help make the claim more reimbursable?

    Unfortunately, no. If there is an error in the superbill, we will correct it, but we cannot alter the service type, length of service, location of service, or CPT code after the fact.

  • Are there any available grants for therapy services?

    Yes, there are grants available through third-party organizations that may help cover therapy services. We've compiled a list of these resources here: https://tumblendots.com/resources/grants/. Please note that we do not manage these funds and are not responsible for any information provided or requested by these organizations.

Additional Support:

We understand that this process can be complex. Our staff is here to provide you with support and any necessary documentation.

Out-of-network reimbursement is the client’s responsibility. In the event the insurance company requests additional documentation, we will work with you to provide the necessary documentation. However, this can be very time-consuming, and thus, any support for your out-of-network reimbursement that requires an excess of 15 minutes of your therapist’s time will be billed to you per our billing policy.