Out-of-Network Patients & Gap Extension Requests
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Out-of-network patients are often able to obtain a Network Gap Extension through the Clinical Services Department of their insurance company, so that a large portion (up to 90%) of the evaluation costs can be applied to their in-network plan. Therefore, if your in-network deductible is low or has been met you may get a reimbursement check from your insurance company.
Importantly, this is always an arrangement between you and your insurance company, it does not involve Dr. Edwards, and Dr. Edwards will not sign paperwork or call your insurance company.
The information provided below should be sufficient to establish a Network Gap Extension from your insurance provider. Requesting a Network Gap Extension may be time consuming and complex, and success is not guaranteed by Dr. Edwards. A Network Gap Extension is not required to see Dr. Edwards, in which case the full cost of the evaluation will be subjected to your out-of-network benefits. For out-of-network services, all payments are due at the time of the evaluation. Costs vary by procedure and involvement, and typically range from $850 to $2000, depending on the type and duration of the evaluation. I suspect that 66% of gap requests are successful when there is a clear medical history (e.g., head injury, seizures, fetal exposure to drugs) . Success without a medical history (e.g., ADHD, depression) is rare, possibly 20% or lower. Insurance companies will NEVER cover academic evaluations.
Single Case Agreements: Sometimes insurance companies will ask that the clinician sign a single case agreement. I do NOT sign single case agreements because it gives the insurance company complete power over the evaluation and reimbursement. I have had insurance companies deny payment after the evaluation was completed, which is not fair to the office or to the patient.
STEPS TO REQUEST A NETWORK GAP EXTENSION
1) Have a referral for Dr. Chad Edwards from an in-network medical provider (e.g., your primary care physician or neurologist).
2) Call your insurance company and request the Clinical Services Department for a Network Gap Extension for a Pediatric Neuropsychological Evaluation. You may need to request to speak to a supervisor.
3) Be prepared to request the following codes (the codes vary by evaluation type and medical history) when calling your insurance company:
* For Neuropsychological Evaluations (significant medical history, such as seizures, genetic conditions, head injury, hydrocephalus, fetal exposure to drugs or toxins, lead exposure, extremely low birth weight, extreme premature birth, concussions, sleep apnea, brain surgery, brain tumors, or cancer treatment, etc...)
Diagnosis Code: G93.40
Interview: 96116 (request 2 units)
Evaluation Support Services: 96132 (request 1 unit), 96133 (request 3 units)
Testing Services: 96136 (request 1 units). 96137 (request 10 units)
*For Psychological Evaluations (no medical history: ADHD, Autism, Anxiety, etc)
Diagnosis Code: Depends on the diagnosis we are primarily exploring, usually the primary concern has something to do with ADHD (F90.2) or Autism spectrum (F48.0).
Interview: 90791 (request 1 unit)
Evaluation Support Services: 96130 (request 1 unit), 96131 (request 3 units)
Testing Services: 96136 (request 1 units). 96137 (request 7 units)
4) Provider information:
Chad Edwards, PhD
Developmental Neuropsychological Services, P.C.
3608 Pleasant St.
South Bend, IN 46615
NPI #: 1861874869
Tax ID: ______________ (They may request my Tax ID but this should be linked to my NPI number in their records)
5) Request the approved authorization in writing.
6) Get the address or fax number for you to send the "Super bill" (see below:)
7) Upon payment at the time of the evaluation Dr. Edwards will provide you with a "Super bill" that has all of the approved procedural codes and your payments, which you then submit to your insurance company to that they can apply it to your in-network benefits.