What Is an Insurance Authorization for Speech or Occupational Therapy?

Many insurance companies require an authorization before speech or occupational therapy services can be delivered. Authorizations are used to “obtain permission” from an insurance company so that they will approve and cover services.

When it comes to authorizations, there is no "one size fits all." Every insurance company is different. However, we’ve put together this overview to help you understand the authorization process and answer common questions.

Key takeaways

• Many insurance companies require an authorization before they will cover speech or occupational therapy.

• Insurance plans use authorizations to manage healthcare costs. They want to ensure that therapy services are medically necessary.

• Most insurance plans require that authorizations are submitted after your therapy evaluation. That way they can review the plan of care documented by your speech or occupational therapist and determine if it meets their standard of medical necessity.

• Some insurance plans will approve authorizations same-day, while others take 14 days or longer.

• Some factors can delay the approval of an authorization, such as not having your physician referral, or waiting for your physician to sign your therapy plan of care.

Why are authorizations required for speech and occupational therapy?

Insurance companies use authorizations to control healthcare costs. They want to ensure that speech or occupational therapy services are medically necessary to diagnose or treat an issue.

Insurance companies often set their own definitions or criteria about what they consider to be medically necessary.

The Centers for Medicare and Medicaid Services (CMS) defines medical necessity as: "Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine."

When are authorizations submitted and what do they include?

For speech or occupational therapy services, most insurance plans require that authorizations are submitted after an evaluation has been completed, but before recurring therapy visits can begin.

Among other criteria, insurance companies want to review the plan of care documented by your speech or occupational therapist and determine if it meets their standard of medical necessity.

While every insurance company has their own requirements, they can include:

• Completed plan of care written by your speech or occupational therapist

• A referral from your physician for speech or occupational therapy services

• A signed plan of care from your physician

• Number of visits requested

• Diagnosis

• Standardized testing scores

• Statement of medical necessity

In some cases, an insurance company may require an authorization for the initial evaluation as well.

How long do authorizations take?

The short answer is that timelines vary by insurance plan. Some insurance plans will approve authorizations same-day, while others have a 10- to 14-day approval process or longer.

What can delay an authorization and start of services?

At Expressable, our goal is to submit authorizations as early and quickly as possible to prevent the delay of services. We are often able to submit and receive approval before your next scheduled visit.

With that said, there are several factors that can postpone the submission and approval of an authorization.

• Physician referral: A physician referral is often required before an authorization can be submitted to your insurance plan. We will reach out to your physician to request a referral, but we also encourage you to contact your physician directly. If you do not have a primary care physician, or if your physician requires that you be seen in-office before sending us a referral, this may also delay services.

• Signed plan of care: Similarly, many insurance plans require that your physician review and sign your plan of care. We will send your plan of care to your physician as soon as it's completed by your therapist, but contacting your physician directly can help speed up the process.

• Authorization approval timelines: We actively monitor the status of authorizations daily. However, insurance companies with long approval timelines can result in services being delayed or rescheduled.

What if my authorization is denied?

Expressable will work diligently with you and your speech or occupational therapist to resubmit or appeal a denied authorization. However, there’s no guarantee that the insurance plan will overturn their decision if they do not consider your services medically necessary.

In these cases, you can switch to our private pay rates if you wish to continue services.

I’ve received services in the past and an authorization wasn’t required

Insurance companies routinely change their rules and requirements for authorizations. Additionally, while many insurance companies temporarily waived authorizations during the COVID-19 pandemic, many are now being reinstated.

Expressable will work with you to help the authorization process move as quickly and smoothly as possible!