Insurance Information

OTA is a Participating Provider for the following Insurances:

• Harvard Pilgrim Health Care (HPHC)
• United Health Care-Harvard Pilgrim (UHC-HP) – United Health Care card with HPHC logo only.
• Blue Cross/Blue Shield insurance (BC/BS)
• Mass General Brigham Health Plan
• For all other insurance companies, we are an out-of-network provider.

Know What Your Insurance Covers

Many insurance plans cover Occupational Therapy and Speech and Language Therapy services, but there may be certain conditions that apply. It is important to know what your plan will cover before you access our services.

Call your insurance company to find out what services your plan covers.

Here are some questions you should ask:

• Does my plan provide coverage for the type of services offered at OTA?
• Are evaluations covered?
• How many therapy sessions are allowed under my insurance plan?
• What out-of-network coverage do I have if I go to a facility/provider that does not accept my insurance?
• Do I need to obtain prior authorization or a referral for therapy services?

You may have benefits for an out-of-network provider or belong to a POS/PPO plan that covers outside facilities. However, OTA may often not be covered by insurance due to the fact that we are a private facility and not affiliated with any hospitals or rehabilitation facilities. If your insurance company has told you that they will reimburse you for our services out of network, OTA will provide you with monthly invoices that you may submit to your insurance company to seek reimbursement. OTA does not bill insurance companies for which they are not participating providers.

If you have secondary health insurance (if another person in your household also has insurance), be sure to check with that insurance company about coverage.

It is your responsibility to understand your coverage and to obtain authorization, if needed, for any out of network services.

OT/SLP Authorization Services Representative

For all insurance for which we are a participating provider we will contact your insurance company to verify your eligibility for therapy benefits. It is important to note that the insurance companies will state that a quote to benefits does not guarantee coverage and that payment is subject to further approval.

We will determine if prior authorization or pre-certification is needed for services. If it is required, we will follow the steps necessary to obtain authorization for therapy services.

We will assist you with any other insurance questions you might have to the best of our ability.

We will provide guidance regarding additional financial resources that might be available to you.

Some of our services are not insurance reimbursable regardless of your insurance policy. We will be clear with you when scheduling any such service that will require an out-of-pocket expense.

Do we need a referral from our physician to come to OTA for services?

OTA The Koomar Center does not require you to have a medical doctor refer you for services, but if you want services reimbursed by an insurance company, it is necessary that you get one. Most clients find it helpful to have a medical referral on record so it is there if needed.

Insurance companies differ regarding the need to obtain preauthorization for services, the number of visits they will cover in a given day or other time period, and whether they require periodic re-evaluations. The client/parent is responsible for keeping track of these requirements. OTA will not be responsible for keeping track of this information for insurances where we are not a participating provider.

OTA will obtain the prior authorization for treatment for occupational therapy clients covered by HPHC and UHC-HP, and for speech and language clients covered by HPHC, UHC-HP, BCBS, and Mass General Brigham Health Plan.

and BCBS. Clients need to provide OTA with a Letter of Medical Necessity from their primary care physician.

What is a Letter of Medical Necessity and when do I need one?

A Letter of Medical Necessity (LMN) is a letter from a primary care physician providing OTA-Watertown with a diagnosis for referring a client for service. All clients need a LMN in order to bill the insurance company accurately and to seek proper reimbursement. If you plan to bill your insurance company or access one of our insurance providers you must provide a LMN prior to receiving services.

What is the difference between a referral and a Letter of Medical Necessity?

A referral is usually an approval number with number of visits provided by the primary care physician for HMO members. A Letter of Medical Necessity is a doctor’s letter with a diagnosis or reason for referring a client to a specialist. A blank Letter of Medical Necessity which you may take to your doctor for completion is available on our website under “Getting Started.”

When do I need to pay if you are also billing my insurance?

If OTA is a participating (in network) provider of your insurance company you are required to pay your co-payment at the time of service.

All other clients receive services through OTA’s Comprehensive Treatment Plan (CTP). Under the terms of this plan, each month of service is prepaid (or the entire course of treatment may be prepaid). You may submit the paid invoices directly to your insurance company

My insurance company said that you cannot bill me directly for your services.

This is only true if OTA is an in-network provider for your insurance company. Our fee agreements state that you are responsible for payment of your bill for services rendered. If your insurance company does not hold a contract with OTA then you are the only responsible party for payment of your bill.

Can my insurance company pay you directly and I only pay the copayment/coinsurance?

Unfortunately, OTA can only do this for insurance companies for whom we are an in-network provider. At this time, they are Harvard Pilgrim Health Care (and some United Healthcare plans with a Harvard Pilgrim benefit) for occupational therapy and speech and language therapy, Blue Cross/Blue Shield for speech and language therapy only.

The insurance company said that you issued an inappropriate code for the occupational therapy evaluation.

OTA uses the code that best fits the extended, sensory-based evaluation that is most commonly done in our office. Our evaluations include assessment of motor, social, adaptive, language, and/or cognitive functioning. We also include an in-depth report and a report meeting as part of the evaluation process. The codes 96112 and 96113 are the codes that best-fit our evaluations.

The claims representative at my insurance company said you used the incorrect diagnosis code.

An occupational therapist cannot diagnose, only evaluate, therefore we use the diagnosis code provided by your physician in the Letter of Medical Necessity. If you do not have this letter, we will be happy to supply you with a form letter for your doctor to fill out. Please request this from the front desk secretary or the client coordinator.

Are there any reduced rates?

OTA does not have reduced rates for evaluations. If you have a serious financial hardship, you may ask at the front desk for a Personal Financial Statement to complete for consideration for intervention services. The completed form, along with a signed copy of your most recent years’ federal tax return (with all schedules) will be reviewed by the Administrative Director for consideration of a reduction in treatment fees (not evaluation fees). The availability of reduced rate services is not guaranteed.