The COLLAGE program is pleased to be able to offer you help with obtaining medical insurance payment. 

I.   PRIMARY INSURANCE

A few primary insurance companies will provide partial payment for COLLAGE services.  We recommend that you call your primary insurance company and ask them about coverage within your particular policy for "out of network group occupational therapy."  Also ask if you have a limit to your number of OT visits per year.  Tell us whether your policy will provide you with any reimbursement and the limit of the  number of visits, if any.  If they will cover, then ask us to send you an “Insurance Statement” after we receive your payment.  Two weeks after the close of each series of COLLAGE group meetings the office issues insurance statements telling days attended and paid for.  You can send the Insurance Statement with your company’s filled out insurance forms to your insurance company’s address.

Should your insurance company ask for a procedure code, you may use the following code:   97150(GO). 

If your primary insurance company requires pre-certification or pre-authorization before treatment can begin,be sure to arrange that with your company. 

If your family member is absent for a session you have already paid for, be aware that insurance companies do not pay for treatment that was not given. 

II.   Medical Assistance

Medical Assistance (M. A.) will cover in-network benefits for COLLAGE-enrolled individuals with certain select diagnoses.  To begin application for MA benefits, please call 1-800-692-7462, then 215-560-2547.   Once you are enrolled with M. A. you can then apply to receive payment for COLLAGE via the Medical Assistance Behavioral Health insurance company that covers the county where you live.  The COLLAGE office will need copies of the following documentation before Michele, our Insurance Coordinator, can apply for your insurance authorization to enter a group series:

Front and back of all medical insurance cards applicable to the enrolling person.  Be sure to include the yellow Medical Assistance card. 

Social Security number and birth date of the enrolling individual

A script/order from your physician for: 

16 group occupational therapy visits for the person named along with

the person’s diagnosis and diagnosis code.

If the physician has questions about either of these or about the COLLAGE program, ask the physician to call the office and ask for Michele, our insurance coordinator.

A Biopsychosocial Assessment that contains multiaxial system results.  It will look like the list below;  it cannot be more than one year old,   and it must contain the signature of the examiner. 

Axis I

Axis II             

Axis III

Axis IV           

Axis V                                GAF

This Biopsychosocial Assessment can be obtained from your psychologist, psychiatrist, or some referring physicians.  It may be sent to the Collage office by mail, fax, or hand delivery.  IEP’s and other school-generated reports are not acceptable as assessments for insurance authorization. 

The above documentation should be sent to Michele by fax, mail, or hand delivery in time for her to complete the several steps of the enrollment process (preferably two weeks before opening day).

Other special considerations about  M. A. Insurance Coverage:

Please call the office before any future 8- or 6-week series you might attend, verify your insurance eligibility, and discuss with Michele whether further insurance steps need to be taken. 

Be sure to notify Michele immediately of any change that occurs in your insurance carrier or your particular insurance plan. 

If you have one or more primary insurance companies plus M. A. coverage, then you must notify Michele immediately when you receive either payment or an E.O.B. (Explanation of Benefits form). 

Regardless of which insurance company insures your family, an authorization number NEVER guarantees insurance payment. 

III.  receipts and Insurance Statements

If you need to receive a statement to attach to your Insurance Company claim form, request an “Insurance Statement.”  It will be issued AFTER an 8-week series ends (or after other service takes place) only if it has been requested and if payment for the service has been received by COLLAGE.  . 

·         It will identify relevant dates, codes, and names of therapists, etc.

·         It will be given after the service has been provided because insurance companies usually will not pay for dates that have not occurred yet or have not occurred at all. 

·         If a person was absent, that date will not appear on the Insurance Statement because insurance companies usually will not pay for those dates.  Therefore, the amount of reimbursement would be less than if the enrolled person had attended all the dates that the family paid for. 

If you need to receive a “Receipt,” on the other hand, it can be given to you any time after payment is received and will list months of service, not dates.  It will be marked “not suitable for medical insurance purposes.”  A receipt may sometimes be used when calculating Income Tax (consult your tax advisor).  Or you may use a receipt for a Flexible Spending Account at your place of business -- for example, if you have unreimbursed COLLAGE expenses, you can request a Receipt stating payments you have made, and the receipt can be turned in at your business to entitle you to reimbursements from your Flexible Spending or Health Savings Account.  

Please remember that it is necessary to ask for an Insurance Statement or a Receipt the first time you need one.  Thereafter it should be sent to you from the office automatically. 

Rationale regarding fees and receipts:  Fees for COLLAGE sessions are based on an educational model of “tuition”-type payment in advance for each series so:

·     …we can determine the makeup of each group, since every member added or subtracted changes the social makeup for the remaining members. 

·     …we can decide when we need to turn away very suitable applicants because of full groups or because of particular other members within a group. 

·     …we can assign therapy personnel required for each group.  

 As with other tuitions, reimbursement cannot be made for absences.  However, insurance companies always reimburse on the medical model of payment after service has been provided. 

·     Therefore, they do not pay for sessions missed by their patient for any reason.

Yet we cannot provide “makeup” sessions. Each series of 8 (or 6 in summer) is with a different group of people – some new to the program, some old, some new to this group but not new to the program.  The social mix is different.

If we should receive payment from an insurance company for a bill previously paid by an enrolled family, we will reimburse the family up to the amount of the insurance payment, excluding any early withdrawal fee.    If you have questions about insurance coverage, please call Michele, our Insurance Coordinator, at 610-356-7355.

Revised 1/7/2010

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