Re: Re: Aetna insurance appeal/Executive Complaint

[Guest guest]

,

Thank you very much for the helpful information!

As to the " correct code " ??...how do you know what that is??? Are there more

favorable ones according to the insurance companies? Everyone keeps telling

me, " it's probably just the wrong code " , but I have no idea what codes to

ask these doctors to try! Any guidance would be GREATLY appreciated!

Thanks to everyone for all the help! I feel like we are wasting so much

time jumping thru all these hoops for a magic code, when the problem and

treatment remain the same.

_____

From:

[mailto: ] On Behalf Of

Sent: Tuesday, November 25, 2008 7:41 AM

Subject: [ ] Re: Aetna insurance appeal/Executive

Complaint

,

From the horse's mouth:

An Executive Complaint is basically a complaint to the President of

the Company. This should be used as your last resort.

First call customer service with the dates of service that were

denied and state that you want to appeal. They will be able to walk

you through it and should be helpful.

Did your ped neuro use the correct code? The " horse's mouth " says

that wrong codes are used all the time.

Hope this helps and keep me posted!

in OH

>

> Ok, help here! We have Aetna, and they have denied all claims for

ST

> because " no speech was lost " and in your children it is

developmental. We

> have the diagnosis from a ped. Neurologist.

>

> Any suggestions?

>

> What is an " Executive complaint " b/c I will call and say I want to

make one,

> and then not know what I am doing :-)

>

> Please .any insurance tips are GREATLY appreciated!!

>

> Another newbie :-)

>

>

[Guest guest]

I have been filling claims with BCBS and have been quite successful so far using

the following codes and description.

 

DIAGNOSIS CODES: 784.69, 315.32

 

and  the following description - K presents with misarticulations due to a

history of verbal apraxia.  He also exhibits both receptive and expressive

langauge disorders, which affect his ability to communicate effectively with his

parents, peers, teachers, and healthcare professionals.

 

hope that helps

 

thanks

sheela

From: <whitmore_dh@...>

Subject: [ ] Re: Aetna insurance appeal/Executive Complaint

Date: Wednesday, November 26, 2008, 3:50 AM

,

Here is an archive of which codes to use (and not use) for insurance:

Archive from

Marilyn Agin, M.D.

Medical Director CHERAB Foundation

-Dear Kari, I wanted to respond to your insurance code question for

apraxia. In the ICD 9 medical code book, #315.4 is Dyspraxia Syndrome.

The confusion is that is that many of the #315 codes are

developmental, but not this one. #784.69 is probably the safer code to

use in that it comes from the section where the codes are neurologic.

I am also adding to this a previous post (#263) which further

elucidates this:

One of the forces that most of our families with apraxic children

have had to deal at some time or another is the medical insurers. If a

medical professional or speech pathologist writes a report or a

bill for submssion to the insurance company, here are some

important tenets to follow:

-Oral/verbal apraxia is a neurologic disorder so never use the word

developmental or a code that is " developmental " in the report or

on the bill. -Useful ICD codes for Apraxia of Speech are #315.40 or

#781.3. The latter code is also one used for Hypotonia, Sensorimotor

Integraton Disorder, and Coordinaton disorder, which may be associated

with apraxia of speech.

-If there is an associated expressive language disorder with the

apraxia, which is commonly the case, use #784.6 which is " other

symbolic dysfunction. " If #315.3, 315.31, 315.39, or 315.9 are used,

these are developmental codes and may not be reimbursed.

Often the insurance co. will ask your doctor to write a Letter of

Medical Necessity of Letter of Predetermination. This needs to state

the appropriate diagnosis and code number, state that the

diagnosis(ses) have a neurologic basis and are not developmental, and

intensive treatment by qualified, experienced speech and

occupational therapists is required. Often you need to state the

specialized nature of the therapy (PROMPT, oromotor, sensory

integration, etc.) and explain why your therapist is more qualified

than the one who is " in network " for provider. Have your therapists

state their specialized credentials and certifications.

-Define apraxia as a speech disorder where the brain signals that go

to the muscles and structures of the speech mechanism are

disrupted.

-Without therapy, children do not outgrow apraxia of speech. Speech

therapy is needed at least 4x week by experienced oral motor speech

therapists. Without this therapy, prognosis for improvement is poor.

-The provider may only provide therapy for 2 months or 6 months

of therapy. Accept it and reapply with new goals set by your speech

pathologist.

Don't be discouraged by a rejection. That's what they want, They

want to wear you down, but don't let them. This is your child and

you have to continue the fight and go to the top person in the plan.

If they tell you this is a preexisting condition, this is absolutely

absurd when talking about a child.

Be advised though, that some insurers are better than others. Some

will never offer speech services unless your child has had a stroke or

accident. (What a horrible thought). If you have a choice of insurers,

make sure you choose one wisely. Look at the benefits before you sign

up.

Good luck!

Marilyn Agin, M.D.

Medical Director CHERAB Foundation

http://www.apraxia. cc

============ =

>

> ,

>

> Thank you very much for the helpful information!

>

>

>

> As to the " correct code " ??...how do you know what that is??? Are

there more

> favorable ones according to the insurance companies? Everyone

keeps telling

> me, " it's probably just the wrong code " , but I have no idea what

codes to

> ask these doctors to try! Any guidance would be GREATLY

appreciated!

>

>

>

> Thanks to everyone for all the help! I feel like we are wasting so

much

> time jumping thru all these hoops for a magic code, when the

problem and

> treatment remain the same.

>

>

>

>