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Autism - Support Across the Spectrum Autism - Support Across the Spectrum

Services Denied!!! Advice?....UPDATE!!!

Posted by on Oct. 5, 2013 at 7:19 AM
  • 17 Replies

Hello ladies!  Ive posted more than several times about my struggles with Ryan.  He will be 3yr in a few weeks.  He's very aggressive.  He has been diagnosed with Autism, ADHD, Disruptive Behavior Disorder, and a TIc Disorder.  So I have all of his Drs aggreeing on the diagnosis, school and in-home services.  They all have mentioned meds but I don't want that just yet.  Id like the training before I resort to that.  I got him into a special-ed preschool and his first day is Oct 28th. So I found a wonderful organization that fit exactly what I wanted for Ryan and the family as far as help and training within the home.  I submitted to the health insurance.  Yeah it was denied.  They denied it because they said my husbands work has to add ABA therapy on, right now the company doesn't allow it to be coverred so I have to submit a form to my husbands HR dpt which will be handed in on monday.  The insurance company said they cover all out-patiendt behavioral health unlimitied amount but not ABA or anything under Autism.  So has anyone experienced this and found a way to get the services.  I feel lost and beyond stressed trying to fight for something this family clearly needs.  Any suggestions and or advice would be greatly appreciated.  Hugs!

        UPDATE:  First Id like to thank you all for your support and replies.  It means more to me than you ladies will every know.  So the update is Im fighting the fight with insurance company.  I submitted the form to my husbands HR dpt and the HR dpt is contacting the insurance to see what they can do to help us since Ryan has several dianosis maybe they can get it covered under somthing else, differenct diagnosis or procedure code.  Ryan's pediatrician is also calling the insurance company to let them know how severe Ryan is and that we need these services.  So with all that going on and stressing me out the organziation that I want to provide the in-home ABA is awesome.  They had a staff meeting and training and Ryan and I got brought up and several staff memebers want to help us for free!  For how long I don't know but hey it buys me some time while I fight the fight to get this approved and Ryan isn't left without services.  So this gives me some peace.  I just wanted to share a little bit of good news since I don't feel like I have that much good to share most days.  Thanks again ladies!!!

by on Oct. 5, 2013 at 7:19 AM
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Replies (1-10):
Stephw1110
by Bronze Member on Oct. 5, 2013 at 7:39 AM
1 mom liked this

Yes last year my husband's health insurance was self pay so they didn't cover anything related to autism.  We still qualfied for our states early intervention but my son has a feeding disorder and needs feeding therapy.  No one in our area was qualfied for this though early intervention.  We had to appeal the insurance company and ask them to cover this service.  They actually agreed but we ended up only using it a few times as our feeding therapy fell though.  Now his company isn't self-pay (don't remember what the word is for it now) and they cover more, including ABA, but it's still been a pain.  We do ABA 5 days a week and I bet they still deny 2 out of 5 days claims.  I contact our company at least weekly to have claims reversed.  Honestly, I think they just deny it hoping they don't have to pay.  Plus we only have a total of 60 therapy visits (OT, SLP, feeding, PT combined).  This year we've been ok with the therapy numbers but I think next year we will have to appeal for a addition time. 

charley31
by Bronze Member on Oct. 5, 2013 at 7:56 AM


So I assume as long as your husband was under the self pay they never approved the ABA therapy huh?  Everything is a damn fight and Im exhausted.  But I wont give up.  I just didnt know if Im fighting for no reason ya know.  I have the form all ready to hand in I forget what its called to get my husbands company to ok it but I doubt they will change things for one family. Wishful thinking.  I just feel stressed at the though of us having no services. He as early intervention now but that stops at 3yr which is 3wks away.  I have him going to a special-ed preschool but that still leaves me without the help and training of how to handle him once he is home.  His drs all say he will keep a lid on his aggression at school and explode at home.  He's soo aggressive and Im just at a loss and bruised, emotionally and physically.  

Quoting Stephw1110:

Yes last year my husband's health insurance was self pay so they didn't cover anything related to autism.  We still qualfied for our states early intervention but my son has a feeding disorder and needs feeding therapy.  No one in our area was qualfied for this though early intervention.  We had to appeal the insurance company and ask them to cover this service.  They actually agreed but we ended up only using it a few times as our feeding therapy fell though.  Now his company isn't self-pay (don't remember what the word is for it now) and they cover more, including ABA, but it's still been a pain.  We do ABA 5 days a week and I bet they still deny 2 out of 5 days claims.  I contact our company at least weekly to have claims reversed.  Honestly, I think they just deny it hoping they don't have to pay.  Plus we only have a total of 60 therapy visits (OT, SLP, feeding, PT combined).  This year we've been ok with the therapy numbers but I think next year we will have to appeal for a addition time. 



SAMI_JO
by on Oct. 5, 2013 at 7:59 AM
4 moms liked this

Unfortuneatlly you will run across this often. But don't give up. Make an appeal to your insurance company. Send it to the CEO, I have learned don't mess around at the bottom of the ladder, go straight to the top.

ineedcoffeemom
by Brittaney on Oct. 5, 2013 at 9:38 AM
1 mom liked this

Our insurance is self pay as well so ABA is not covered ..... ECI services aren't even covered, but because it's state funded we're paying on a sliding scale so it's affordable. I'm still fighting our insurance company just to give me our summary plan description because I'm not even sure WHAT medical codes are covered and what aren't and which therapies for each and so on ..... So I've given up on my insurance and I'm applying for Medicaid Buy-in. I live in Texas and in Texas this program you can apply for Medicaid but pay a deductible, then medicaid will cover any services denied by your insurance. The only catch is you have to keep your child on your insurance too ..... so you're paying for 2 insurance premiums but if you're within income limits, sometimes medicaid will pay the premium from your employers insurance.

I'm just waiting to see if I'm denied this ....sigh

wildchild.com
by Janine on Oct. 5, 2013 at 10:45 AM
1 mom liked this
I remember my son was denied speech therapy & the therapists had to resubmit the order. Apparently she had to word it differently & we got approved. I would just keep pushing for these services.
charley31
by Bronze Member on Oct. 5, 2013 at 11:04 AM
Thank you. I asked the social worker that I have if we can just use a diff word other than ABA and submit that. I don't think there's a diff way to word that tho.


Quoting wildchild.com:

I remember my son was denied speech therapy & the therapists had to resubmit the order. Apparently she had to word it differently & we got approved. I would just keep pushing for these services.

momofblueeyes04
by on Oct. 5, 2013 at 12:09 PM
1 mom liked this
The best thing I can say is go one medi are I know it sounds bad but bc of his diagnosis they should cover everything and income shouldn't matter bc of the diagnosis. I actually have to so the same thing for my kids


Quoting charley31:

Hello ladies!  Ive posted more than several times about my struggles with Ryan.  He will be 3yr in a few weeks.  He's very aggressive.  He has been diagnosed with Autism, ADHD, Disruptive Behavior Disorder, and a TIc Disorder.  So I have all of his Drs aggreeing on the diagnosis, school and in-home services.  They all have mentioned meds but I don't want that just yet.  Id like the training before I resort to that.  I got him into a special-ed preschool and his first day is Oct 28th. So I found a wonderful organization that fit exactly what I wanted for Ryan and the family as far as help and training within the home.  I submitted to the health insurance.  Yeah it was denied.  They denied it because they said my husbands work has to add ABA therapy on, right now the company doesn't allow it to be coverred so I have to submit a form to my husbands HR dpt which will be handed in on monday.  The insurance company said they cover all out-patiendt behavioral health unlimitied amount but not ABA or anything under Autism.  So has anyone experienced this and found a way to get the services.  I feel lost and beyond stressed trying to fight for something this family clearly needs.  Any suggestions and or advice would be greatly appreciated.  Hugs!


wildchild.com
by Janine on Oct. 5, 2013 at 12:26 PM
1 mom liked this
Quoting charley31:

Thank you. I asked the social worker that I have if we can just use a diff word other than ABA and submit that. I don't think there's a diff way to word that tho.


Quoting wildchild.com:I remember my son was denied speech therapy & the therapists had to resubmit the order. Apparently she had to word it differently & we got approved. I would just keep pushing for these services.



Doctors & therapists have to stress how much your son needs this service.Ask them to send documented proof stating this is absolutely necessary to your sons well being. Keep pushing mama you are your sons voice!Good luck & let us know what happens.
MomOfOneCoolKid
by Gold Member on Oct. 5, 2013 at 5:13 PM
1 mom liked this

Ugh! No, I tried to. My insurance didn't cover it either. I wonder if the new healthcare exchanges will cover it? That would be awesome.

darbyakeep45
by Darby on Oct. 5, 2013 at 6:57 PM
1 mom liked this

I'm sorry mama!  Hugs!  My insurance does cover my son's ABA therapy.

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