Out-of-Network Reimbursement Guide
Getting money back from your insurance, explained step by step.
We are an out-of-network pediatric occupational, speech, and feeding therapy clinic in Irvine. This guide covers what to ask your insurance, what we hand you, and how families across Orange County actually get reimbursed.
How out-of-network reimbursement works, in short
- You pay us directly. We are not in any insurance network, so payment is due at the time of service, no matter what your claim does later.
- We give you a superbill. That is an itemized receipt with every code your insurance needs. It arrives by email on the 1st and the 15th, and it is always waiting in your parent portal.
- You send it to your insurance. Most plans accept it through their app or member website in a few minutes.
- They pay you, not us. Whatever your plan covers goes straight back to you as a check or a deposit.
Reimbursement here is common, not rare
Parents ask us this before they ask anything else, so here it is plainly: our families get reimbursed regularly. When a plan includes out-of-network benefits, it is normal for a parent to get back a meaningful share of what they paid, and some plans reimburse the full amount.
We cannot put a percentage on it, and we would rather say so than guess. Insurance pays you directly, not us, so we only hear how a claim went when a family tells us. What we can say is that two families with the same insurance company often have very different plans, which is exactly why the ten-minute phone call below is worth making before you assume the answer is no.
Start here
Five words your insurance will use
You will hear these on the phone. Here is what each one actually means for your family.
- Superbill
- The itemized receipt we give you. It lists the date, the service, the codes, and what you paid. It is the one document your insurance needs from us. We break it down field by field in what is a superbill.
- Deductible
- What you pay out of pocket in a plan year before your insurance starts contributing. Out-of-network care usually has its own separate deductible, apart from your in-network one.
- Coinsurance
- Once the deductible is met, the share your plan pays. For out-of-network therapy this is commonly 50% to 80%.
- Out-of-pocket maximum
- The ceiling for the year. Once you reach it, your plan covers 100% of covered costs for the rest of the plan year.
- EOB
- Explanation of Benefits. The statement your insurance sends after processing a claim. It shows what they allowed, what they paid, and why. It is not a bill.
The process
How to get reimbursed, in four steps
Steps 1 and 2 happen before therapy starts. Steps 3 and 4 repeat as you go.
Call your insurance and check your benefits
Use the member services number on the back of your insurance card and work through the script below. One call tells you whether your plan has out-of-network benefits and roughly what to expect back.
Ask your pediatrician for a referral
Many plans require a written referral or prescription naming your child's diagnosis and the service: occupational therapy, speech therapy, or feeding therapy. Ask for it early. It is far easier to have one and not need it than the reverse.
Come to therapy and pay as you go
Payment is due at the time of service. Your insurance claim does not change what you owe us or when, because we never receive money from your carrier.
Submit your superbill and watch for the EOB
We email your superbill twice a month, on the 1st and the 15th. It is also available any time in the parent portal. You submit it to your plan, usually by uploading it in their member portal or app.
Ten minutes, one call
How to check your out-of-network benefits
Print this page or keep it open, then call the member services number on the back of your card. Write the answers down as you go.
Out-of-network benefits check
Read the opening line, then work down the list.
"Hi, I'd like to check my out-of-network benefits for pediatric occupational therapy, speech therapy, and feeding therapy for my child."
- Does my plan include out-of-network coverage for occupational therapy, speech therapy, and feeding therapy?
- Is there a separate out-of-network deductible, and how much is it?
- How much of that deductible have we already met this plan year?
- After the deductible, what percentage do you reimburse for out-of-network therapy?
- Is there a limit on the number of therapy visits per year?
- What is my out-of-pocket maximum for out-of-network care?
- Do I need a referral or prescription from my child's doctor?
- How do I submit a superbill for reimbursement, and is there a filing deadline?
- May I have your name and a reference number for this call?
Always get that reference number. If the plan later tells you something different, the reference number is your proof of what you were quoted, and it is the single most useful thing you can walk away with.
Have this ready
Our provider information: Tax ID, NPI, and address
The representative will ask who the provider is. Everything they need is here.
Tumble N' Dots, Inc.
Pediatric occupational, speech, and feeding therapy. Irvine, California.
- Tax ID (EIN)
- 81-3640988
- NPI number
- 1376045385
- Address
- 15265 Alton Parkway, Suite #140, Irvine, CA 92618
- Phone
- (949) 835-3746
- Taxonomy codes
- 225X00000X Occupational Therapist
- 225XP0200X Occupational Therapist, Pediatrics
- 235Z00000X Speech-Language Pathologist
- 193200000X Multi-Specialty Group
Therapy codes
The CPT codes they may ask about
CPT stands for Current Procedural Terminology. It is the shorthand insurance uses for what happened in a session.
| Code | Official name | What it means |
|---|---|---|
| 97530 | Occupational therapy, therapeutic activities | A standard OT session. |
| 97166 | Occupational therapy evaluation, moderate complexity | The initial OT evaluation. |
| 92507 | Speech-language treatment, individual | A standard one-on-one speech session. |
| 92523 | Speech-language evaluation, low complexity | The initial speech and language evaluation. |
| 97150 | Group therapeutic procedures | Our social skills groups and other group programs. |
| 99368 | Professional consultation, indirect | Time your therapist spends on your child's care outside the session, such as a call with their teacher or physician. |
Clear expectations
What we handle, and what stays with you
Being direct about this up front saves everyone frustration later.
We will
- +Give you a superbill with every code and detail your plan needs
- +Fix a genuine error on a superbill right away
- +Provide supporting documentation your insurer requests
- +Answer your questions about codes, dates, and paperwork
We cannot
- ×Bill your insurance or accept payment from them
- ×Complete preauthorization forms, which ask for information we either do not have yet or are not able to provide
- ×Change the service type, session length, location, or CPT code after a session has happened
- ×Predict or guarantee what your plan will pay
Worth trying
Five ways families improve what comes back
Request an out-of-network exception Biggest impact
Also called a gap exception. If your plan has no in-network pediatric OT or speech provider in Orange County with the right availability or expertise, you can ask your insurer to cover our services at in-network rates. It takes a few calls and some persistence, and when it is granted it changes the math substantially. Our step-by-step guide to requesting a gap exception covers what to say and what to document.
Pay with HSA or FSA funds
Pediatric therapy generally qualifies as a medical expense, so using those dollars saves you the tax on every session whether or not a claim is reimbursed. Confirm with your plan administrator first.
Get the referral with a diagnosis on it
Even when a plan does not require one, a referral from your child's physician that names the diagnosis and the recommended service tends to move a claim through with fewer questions.
Do not stop at the first denial Often overlooked
Claims are denied for missing or mismatched paperwork more often than for lack of coverage. Call and ask exactly what was missing, then resubmit or file an appeal. Parents who ask that one question frequently get the claim paid on the second pass.
Look into therapy grants
Third-party organizations offer funding that can help with therapy costs. We keep a running list on our grants resource page. We do not manage these funds and are not responsible for information those organizations provide or request.
Questions we get
Frequently asked
What if my insurance won't reimburse the whole amount?
That is the usual outcome, and it is still worth doing. Most plans reimburse a portion rather than the full rate. Some of our families do receive the full amount back. Your plan may pay none, some, or all of it, and the only way to know your range is to check your out-of-network benefits using the script above.
Will you complete a preauthorization form for my insurance?
We are not able to. These forms typically ask about the diagnosis, the recommended course of treatment, and a provider social security number. That is either information we do not have before services begin or information we cannot provide.
If my insurance agrees to treat you as in-network, can you bill them?
No. Every insurance company submits claims differently, and we are not set up to determine and follow each carrier's process. Being treated as in-network usually means a higher reimbursement for you, which is good news, but the claim still goes in from your side.
Can a superbill be adjusted to make a claim more reimbursable?
If there is a genuine error, we will correct it right away. We cannot change the service type, length of service, location of service, or CPT code after the fact. Those describe what actually happened, and altering them would be inaccurate.
Why isn't Tumble N' Dots in-network with insurance?
Staying out-of-network lets your child's care plan come from their therapist rather than from a coverage rule. In-network contracts commonly limit session length, visit frequency, and how goals must be written.
- Therapy decisions made by your care team, not your insurance company
- Longer sessions
- The same therapist week to week
- Child-led, play-based sessions
- Parent support built into the process
Are there grants available for therapy services?
Yes. Several third-party organizations offer funding that may help cover therapy. We keep a list on our grants page. Please note that we do not manage these funds and are not responsible for any information these organizations provide or request.
How long does reimbursement usually take?
Most plans process a clean out-of-network claim within a few weeks of receiving it, and you will get an EOB explaining the outcome. If more than a month passes with no EOB, call and confirm they received your superbill. Claims do occasionally get lost on the way in.
Why we are out-of-network
We built the practice this way on purpose. Out-of-network means we answer to your child's progress rather than to a claims department, and it is what allows the parts of our care that Irvine and Orange County families tell us matter most.
- >Session length and frequency set by clinical need
- >Consistent therapists who know your child
- >Child-led, play-based, neurodiversity-affirming sessions
- >Parent coaching built into the process, not added on
- >Goals written for your family, not for a claim form
Read the full explanation of in-network versus out-of-network therapy.
We are here for this part too
Stuck on a claim? Ask us.
This process can be confusing, and you do not have to work it out alone. Text or email us and we will help you figure out the next move.
Irvine, CA 92618
Out-of-network reimbursement is ultimately between you and your insurance company. We will provide documentation your insurer requests. Because that work can be time consuming, any support for your reimbursement requiring more than 15 minutes of your therapist's time is billed to you under our standard billing policy. Nothing on this page is a guarantee of coverage or payment.