Private Health Plans

Tips for Ensuring That Speech and Hearing Services Are Covered

How Do I Know What Speech and Hearing Services My Health Plan Covers?

Read your health plan. If you do not have a copy, ask your employer's benefits manager for one.

• For speech and language services: Look for terms such as speech-language pathology, speech therapy, speech pathology, other rehabilitation services, or other medically necessary services.
• For audiology services: Look for terms like audiology, hearing care, other rehabilitation services, or other medically necessary services. Hearing care may also be found under diagnostic services.
• Make sure coverage includes both evaluation and treatment (or therapy) services.
• Note any limitations and exclusions of coverage

Private health plans often limit or exclude certain services. Common limitations and exclusions include:

• No coverage for speech or hearing disorders that are developmental or present at birth (congenital).
• Coverage only for conditions acquired later in life or care that is “restorative” or “rehabilitative.”
• Exclusions for some conditions, such as stuttering or autism.
• A dollar limit on how much the plan will pay for speech or hearing services.
• A maximum number of therapy sessions that the plan will cover.
• Services that are covered only in certain settings, like a hospital or clinic.
• No coverage for devices such as hearing aids or speech-generating devices.

Always review your plan’s benefits and talk to your provider or benefits manager to understand what is—and isn’t—included.

How Do I Find More Information About What Is Covered?

If you’re unsure whether your health plan covers speech or hearing services:

• Call the number on your insurance ID card and ask to speak with a customer service representative.
• Ask them to send you the details in writing, so you have a clear record of what’s covered.
• Make note of the date, time, and name of the person you spoke with.
• Keep copies of all documents. This information can be helpful later if you need to follow up or file a claim.

Do I Need Approval Before My Visit?

Some health insurance plans require you to get approval before receiving speech, language, or hearing services. This may be called:

• Pre-authorization: The health plan checks whether the care is covered before you receive it.
• Pre-certification: You need to notify the health plan before having certain tests or procedures. The health plan will give you an authorization number.
• Pre-determination: Your provider must ask the plan to confirm that the service or procedure is covered under your policy.

Every plan is different. Before scheduling any speech or hearing service, always check with your health plan.

To find out what your plan requires, call the number on your insurance card and talk to a customer service representative. Be sure to ask if approval is needed—and get their response in writing.

Keep in mind: Getting prior approval does not guarantee your plan will pay for the service.

School Services vs. Medical Services: What Families Should Know

Children can receive speech and hearing services through both the school system and the medical system. The rules are different for each system, creating confusion and gaps in care.

How Speech and Hearing Services Work in Schools

Public schools are required to provide speech services to children who qualify under strict federal regulations and state education laws. But even when a child qualifies, there may be a waiting list before services begin.

Families sometimes turn to outside providers to get additional support and reduce delays in care.

What Health Plans May Not Cover

Families can be surprised to learn that many private health plans won’t pay for services if the insurance company believes the school can provide those services. Unfortunately, families often don’t find this out until after they’ve been denied coverage. As a result, children may not receive the support they need from either one.

Why Collaboration Matters

Communication challenges affect both health and education. That’s why children are best served when school and medical providers, including audiologists and speech-language pathologists, work together to make a plan that meets a child’s needs.

Children can benefit when they receive services from both systems at the same time—with school-based and medical providers working as a team.

When providers work together, children can get the right support in the right setting—helping them grow, learn, and thrive.

How Do I Submit a Claim for Services?

Some speech-language pathologists and audiologists will file insurance claims on your behalf. Others may ask you to submit the claim directly to your plan.

If your provider has a contract with your health plan (the provider is “in-network”), they are required to file the claim for you. If they are not in-network (“out-of-network”), they may give you the information you need to submit a claim, including diagnosis and treatment codes.

How Do I File an Insurance Claim Myself?

1. Get a claim form from your insurance provider or find the section of their website where you can submit a claim. Fill out the form completely.
2. Check the deadline for filing. Some plans require claims to be submitted within a certain number of days—you can find this in your summary of benefits.
3. Attach any required paperwork, such as a treatment plan, a bill from your provider, or a referral from your doctor.
4. Keep copies of everything you send in. Write down the date, the time, and the name of anyone you speak to at your health insurance company.

How Do I Appeal if My Claim Is Denied?

If your health insurance company denies your claim, you have the right to appeal. Denials can happen for many reasons, but that doesn’t mean the decision is final.

• Act quickly—don’t wait. Most states have deadlines for when you must file an appeal.
• Once you submit the claim, your insurance company also has a limited amount of time to respond. Check your plan and state guidelines.

Prepare Your Appeal

Before you submit your appeal, take these steps:

Understand the Appeal Process

• Review your health plan’s appeals process, so you know what is required.
• Collect supporting information, such as documentation of services, treatment plans, and health plan language.

Get the Denial Reason in Writing

• Ask for your Explanation of Benefits (EOB)—this tells you why the health plan denied your claim.

Check Your Coverage Details

• Review your plan’s contract or policy (not the benefits summary) to determine if the service is listed as a benefit under your plan.

If Your Claim Was Denied Because the Service Is Not Covered:

• Check your plan’s contract or policy to see if the service is included as a benefit.
• If it is a covered benefit, include that portion of the policy with your appeal.
• Ask your doctor to write a letter of medical support explaining why the service is necessary.

If Your Claim Was Denied Because the Service Is Not Medically Necessary:

• Find out if the service is a recognized treatment for your condition. You may need to show that the service is medically necessary—that it was provided for a medical reason, is usual and appropriate for your condition, and was ordered by a licensed physician (if required).
• Ask your doctor to write a letter of medical support explaining why the service is necessary.

Submit Your Appeal

Write an Appeal Letter

Your appeal letter should include:

• Your name and health plan ID number(s)
• The subscriber’s name (if different from yours)
• Date the service was provided
• A short explanation of why you’re appealing
• A request that the appeal be reviewed by a speech-language pathologist for speech-, language-, and swallowing-related services, or an audiologist for hearing-related services.

Attach Supporting Documents

The EOB showing the denial.

The section of your policy that shows the service is covered.

A letter from your doctor.

Any treatment plans, test results, or other helpful documents.

Send the Appeal Letter

Address the appeal to the correct person or department at your health plan. If you are unsure, call customer service to ask which person or department reviews appeals.

Send the letter by certified mail with return receipt, so you have proof they received it. Keep the return receipt with the signature from the health plan representative.

Follow Up on Your Appeal

Stay in Touch

• Check in regularly with your health plan to track the status of your appeal.
• Keep detailed records of your contact with your health plan—date, time, name of anyone you talk to, and what they said.

Don’t Give Up After One Appeal

• If your first appeal is denied, you can appeal again. Many decisions are reversed after a second or third attempt.

File a Complaint if Needed

If you believe your claim is being denied unfairly, or your plan is not giving you the information you need in a timely manner:

• File a complaint with your state insurance commissioner.
• Visit the National Association of Insurance Commissioners website to find contact details for your state.

The state insurance commissioner may investigate your case. Health plans usually take these complaints seriously.

What Is an External Review?

If you’ve gone through all your health plan’s internal appeals, and they are still denying your claim, you have the right to request an external review. An independent reviewer (who is not part of your insurance company) will look at your case and decide if the service should be covered.

Here’s what you need to know:

• You must file a written request for an external review within four months of receiving a notice or final determination from your insurer that your claim has been denied.
• All U.S. states must offer an external review process that aligns with federal consumer protection standards.
• By law, your insurance company must accept the external reviewer’s decision.
• Your state’s Consumer Assistance Program (CAP) or Department of Insurance may be able to help you file an internal appeal or external review.

An external review gives you another opportunity to get the care you need—as determined by someone with no ties to your insurance company.