To determine the reimbursement percentage for out-of-network providers, we recommend contacting your insurance company directly. They can provide you with specific details on reimbursement rates and any relevant limitations. Don’t forget to ask them how will the services be reimbursed. Does it go straight back into your account or do they send a check to you? They can also provide you with the precise details of your coverage and any applicable co-pays, deductibles, or co-insurance.

Please consult with your insurance provider to determine if approval or pre-authorization is necessary for occupational therapy services. They will be able to guide you through any required steps or documentation needed.

To understand your deductible status, we recommend reaching out to your insurance provider. They can provide you with information regarding your deductible amount and whether it has been met for the current coverage period.

For information about the number of therapy sessions covered by your health insurance per year, it's best to contact your insurance provider directly. They will be able to provide you with the specifics of your coverage in terms of session limits.

A "gap exception" or "coverage exception" is a term used in the context of insurance to describe a process where an insurance company makes an exception to their coverage policy for a specific service or treatment. In the context of occupational therapy, a gap exception may be requested when an insurance company does not typically cover a particular service, like Sensory Integration (SI) occupational therapy or Comprehensive Behavioral Intervention for Tics (CBIT) but there is a valid medical necessity for the therapy.

This typically requires written approval or prescription from the physician specifying the need for “Sensory Occupational Therapy Evaluation” or “Comprehensive Behavior Intervention for Tics Occupational Therapy,” and additional documentation explaining medical necessity and why the requested therapy is essential for the client's well-being and functional outcomes.

The insurance company will review the gap exception request and consider factors such as the client's diagnosis, supporting medical documentation, and the therapeutic benefits of the requested service. Based on their evaluation, the insurance company may approve the exception, providing coverage for the therapy that would otherwise not be covered under the standard policy terms.

It's important to note that the process and criteria for gap exceptions may vary between insurance companies. Clients and healthcare providers should review their insurance policy and consult with the insurance company directly to understand the specific requirements and procedures for requesting a gap exception for occupational therapy services.