Your insurance company may reimburse fewer hours than billed. For example, some insurance companies only reimburse up to 12 hours of psychological testing, whereas 12-18 hours are typically billed for a full evaluation. It is your responsibility to verify coverage with your insurance company prior to consenting to services. While we do all we can to provide accurate estimates of coverage and benefits, we cannot control insurance companies interpretations or your policy coverage amounts. You are ultimately responsible for all charges incurred from our services.
Any late cancellation fees are not covered by insurance. Also, for assessments Genesis has a testing fee which covers administrative tasks which do not have associated codes to charge to insurance, this amount is clearly stated in your contract.
Initial assessment and therapy appointments are filed with in-network insurance within 1 week of the appointment.
For assessments for “in-network” insurance, the amount which is listed in your contract will be submitted once the final report is complete. This submittal will include all testing and feedback appointments, scoring, review of records, diagnosis and report writing time.
You will receive an explanation of benefits (EOB) form from your insurance company which will provide many details, but the total amount paid to us should be close to the estimated coverage amount provided in your signed contract.
No – claims cannot be processed without a diagnosis code. If you decide you will file your services with your insurance company, please be aware that any diagnosis made will become part of your child’s permanent insurance record. The only way to keep the diagnosis code from your child’s record is to pay out of pocket.
If you are looking to be seen in person (in our office) then you will need to check with your insurance carrier if they will accept North Carolina providers as “in-network” for your specific policy. Due to professional licensing restrictions, we cannot at this time provide telehealth appointments with clients who are calling from another state.
What this means is that we cannot submit claims to your insurance carrier on your behalf. For therapy, we can provide a receipt which can be used for you to submit as a claim. For assessment, once the final report is complete, we will provide you with a comprehensive superbill for you to submit as a claim to your insurance carrier. What coverage you will have for these services is determined by your individual insurance policy for mental health.
I have an insurance provider you have listed as “in-network” but they are saying you are “out of network” why is that?
Sometimes insurance policies specify that clients can only see a select group of approved providers. Your insurance carrier can provide details as to why your particular plan does not include all providers within the paneled network.
Genesis Clinical Services is on the panel with Blue Cross Blue Shield and Medcost, with some providers also individually approved for Aetna.
We are approved as an Out of Network Preferred Provider for Tri-care.
My insurance is requesting a letter of medical necessity or a form to be completed for a one-time case approval, can you help?
After the initial appointment, the psychologist can help complete the forms or provide a letter of medical necessity based upon background data provided and the initial appointment discussions only. We cannot ethically cannot provide diagnosis codes for the client after this initial meeting, but can provide suspected diagnoses which we recommend testing for.
My preauthorization for assessment was denied or only partially approved, what can I do to change that?
Preauthorization denials or partial approvals are able to be appealed within a certain time frame. This appeal must come from the client or the client’s responsible party (parent or caregiver). Genesis can provide support by sending any clinical information, and a provider recommendation of testing coverage based upon the background information and appointments which have occured. Once you have the appeal started, please contact us to coordinate needs.
For minors, any testing considered “educational” to test for learning disabilities, attention or achievement level will typically not be covered unless this testing is part of a group of tests looking at other psychological conditions. Since the public school system can evaluate for educational issues, insurance companies may consider any private educational testing not “medically necessary” and deny claims. If your testing will be purely educational in nature, we strongly recommend you call and discuss the client’s case with your insurance company before starting the assessment process, to confirm what will be covered.
If you intend to submit claims to your insurance carrier and your policy has a preauthorization requirement, then yes this needs to be completed before any testing can occur. Genesis can submit this for you as it will need clinical information and coding. We will provide you a form to gather information of what is needed and who we will submit it to.
Preauthorization may be required by an insurance company for assessments. This is determined by the coverage guidelines of individual policies. If pre-authorization is required and not obtained, insurance companies will deny any claims filed so it needs to be completed before any testing is to occur. Pre-authorization is not a guarantee of insurance reimbursement.
Insurance companies have teams of specialists who will review and approve coverage for assessment services only once the assessment is complete and the resulting diagnosis is provided. They do not consider psychological testing “medically necessary” for “experimental” or “investigational” diagnoses. Diagnoses considered “experimental” or “investigational” vary depending on the insurance carrier and are subjective to the review team they have in place.
Since mental health insurance can be subjectively reviewed by your insurance carrier, we legally cannot take responsibility for determining your coverage should the final result be different from the original estimate. As a provider we also are limited in our access to your specific policy information, and are not provided details such as family deductible and if our providers are considered “in-network”.