Next Step Therapy Blog: The Denial Letter

Tracy Cowles, CEO and owner of Next Step Therapy, talks about “things that every parent of a special needs child should know.”

As a parent of a child with special needs, you will undoubtedly find yourself filling out paperwork to apply for Social Security Disability benefits, insurances, programs, and potentially grants. You may have to submit paperwork for specialty equipment, like wheelchairs and communication devices.

We want you to know that many, many, “claims” are rejected the first time that they are submitted. While this can feel like a tremendous blow, knowing that very few things are “approved” the first time through can help you to manage the situation.

When you receive a “denial” letter, regardless of where it’s from or what it’s for, do not throw it away and assume that you are done. Denial letters are generated for a whole host of reasons, some of which are caused by a minor problem. If a birth date or social security number is written incorrectly, a claim will automatically be rejected. All medical and therapeutic treatments have a “code” that needs to be written in. If the wrong code is written it results in an automatic denial.

A request for an insurance company to pay for equipment requires a great deal of time and documentation. Initial requests are often sent back requiring addition information. This is the norm.

Here is an example: A 10 year old child with severe Cerebral Palsy has outgrown their car seat, and does not have enough muscle control to be able to ride in the car with just seatbelts. Car seat manufacturers do not make a car seat this large, or with features for head control. Therefore, a specially made car seat from a medical equipment company is necessary. Now, that doesn’t sound too crazy, does it? Well, it’s not, but if you are the insurance company reviewer, who doesn’t know anything about this child, seeing a $1200 bill for a car seat for a 10 year old can be disconcerting. This request for a car seat is going to need an evaluation from a licensed Physical Therapist who states that it is medically necessary, a letter from your child’s doctor that says that it is medically necessary, and in all likelihood, a list of all car seat manufacturers that your therapist has investigated to try to find a cheaper, equally effective car seat.

Every reviewer from every insurance company or agency is charged with the task of making sure that all money they authorize to be spent is a genuine claim, and reasonable. The denial letter is not intended to blow your gaskets.

Please know that even at our office, with staff who submit insurance claims every day, we have had to resubmit claims as many as six times.

So, take a tip from the professionals: When you receive a denial letter, read it carefully to see why the claim was rejected. Get help from someone if you don’t understand it. Resubmit with corrections and/or additional information. Repeat as necessary.

Tracy