Insurance Coverage

It is important to understand your insurance company’s coverage policy. The clinician and team treating you can investigate your coverage, get prior authorization, and help you file claims or provide you a summary of care to send to your insurance company for reimbursement. Ask your team if they are in-network, or out-of-network for your insurance coverage. Call your insurance company or have a significant person in your life ask several things so that you will have a good idea of the overall payments, which you will have to make for your treatment.
When you call your insurance company, take notes about the call. What number did you call? Did they transfer you? Get the name and telephone number of the person with whom you talk. This is documentation will help if you have call someone again; you can then reach the same person.

Your treatment team may make some of these calls for you. We encourage you to make these calls yourself or ask a friend or a family member to call. Ask your insurance company representative the tough questions, so that you will be informed:

    1. Start with, “what is your name and how can I call you back if I have more questions”? (Talking to the same person is incredibly helpful and efficient.)
    2. “Do I have a deductible? Is the in-network deductible the same as the out-of-network deductible?”
    3. “What are my deductible(s)?
    4. “Do I have any co-insurance payments, which you will have to pay after my deductible is met? Are they different for in-network and out-of-network?”
    5. “What is the insurance company’s allowable rate per session?”


      • Rate per initial Motor Threshold and initial treatment session (what they call a “90867”)?
      • Rate per subsequent treatment session (what they call a “90868”)?
      • Rate per repeat Motor Threshold session and a treatment session (what they call a “90869”)?
    1. “What will the insurance company pay per treatment?” (What they pay is generally is not the same as the allowable rate.)

Insurance companies like assessment scores. Scores are often required for health insurance prior approvals for coverage determination (the scores can help you get treatment authorized). In addition, the weekly follow-up scores are good for continued coverage and appeals, particularly if your policy decides to try to limit the number of TMS sessions you receive. These assessments are important for insurance to establish your baseline so that if they reevaluate your care, they can assess how well the treatment is working for you. If your insurance company is not paying for your care, or you are paying privately for your care, you may want to share your assessment scores with the insurance company to help with the appeal for reimbursement of your care. At the end of each week in the workbook you will find TMS daily log sheets on which you may record your scores as well as other helpful information. You will use these log sheets daily.

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