Vision Therapy Practice Builder Manual

 

Patient Insurance Information  

 

 

Overview: 

 

Included in this section are some templates of letters we send to Insurance Companies requesting more information on a specific patient. While we are an out of network provider, we do offer to send Pre-Determination (also called Prior Authorization) or Appeal letters at the patient's request. We add the patient Visual Profile Chart and Initial Evaluation Exam to be sent with the Pre-Determination letter. For the Appeal Letter we send appropriate information not limited to: research studies, news articles, additional patient information, etc…  The following forms are included in the manual and make the job of helping your patients achieve insurance coverage for vision therapy much easier.  The manual also explains how to submit the forms to the insurance companies. 

 

 

Forms: 

 

General Information:

 

1. Insurance Questions 

        These are some very basic questions we encounter regularly. These questions usually will lead to more in-depth questions that you will have to answer specific to your clinic. 

 

 

2. How to Inquire About Insurance Coverage 

        This form is what we given the patient and/or parent at the consultation. It is a basic guide for what they need to ask their insurance company when trying to determine potential coverage for vision therapy services. See the Program Guidelines & Finances section under Consultation for more information. 

 

 

Pre-Determination Letters:

 

1. Convergence Insufficiency (CI) Pre-Determination Letter 

        This template is used for patients with the CI diagnosis and any additional accompanying diagnoses.

 

2. Convergence Excess (CE) Pre-Determination Letter

        This template is used for patients with the CE diagnosis and any additional accompanying diagnoses.

 

3. Esotropia (ET) Pre-Determination Letter

        This template is used for patients with the ET diagnosis and any additional accompanying diagnoses.

 

4. Exotropia (XT) Pre-Determination Letter

        This template is used for patients with the XT diagnosis and any additional accompanying diagnoses.  

   

4. Refractive Amblyopia (Amb) Pre-Determination Letter

        This template is used for patients with the Amblyopia diagnosis and any additional accompanying diagnoses. This is changed appropriately when the patient is diagnosed with a different form of Amblyopia.  

 

 

Appeal Letters: 

 

If a patient is denied coverage and has appeal rights, we will write an appeal letter for the patient. Prior to writing an appeal letter, we require written verification that coverage has been denied. Such as: Denial letter, EOB if explicit enough. If the denial is due to an exclusion we do not write an appeal letter. We will talk to the patient and explain what an exclusion means. We have included copies of sample appeal letters for the following reasons: 

 

1. Medical Necessity Appeal Letter 

 

2. Peer Review Appeal Letter 

 

3. Post Surgery Appeal Letter