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Denial of Claim for an SGD

Lewis Golinker, Esq.

October 10, 2011

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Question

What should I do if a claim I submitted for a client to receive an SGD was denied due to an error I wrote in the report?  Should I complete a new AAC evaluation and start the process over?

Answer

I don't recommend that people start the process over.  Appeals will allow additional information to be submitted and if the report that was sent in initially has any flaws, my advice would be to have the SLP to update it. Just to give an additional example - a particular insurance agency has communication device coverage criteria that is modeled on the Medicare guidelines.  This insurance agency says that if the report from the SLP doesn't follow the guidelines they're going to turn it down.  And in a particular example that I handled recently, the speech pathologist failed to answer one of the questions that is in this insurance agency’s guidelines.  I spoke to the speech pathologist and asked that the question be addressed; that he/she fill in the blank.  This addendum letter to the SLP report was prepared and was submitted as part of the appeal which led to the device being approved. 

In cases like this one, and in any case in which the funding source has SGD coverage criteria, I recommend that SLPs submit a statement, either as an introduction to the report, or as an independent note, that acknowledges the SLP is aware of the coverage criteria, and that each element of the criteria has been addressed in the report. By this statement, the SLP is putting the funding source on notice that the SLP was aware of all the information necessary to present, and did so.  This task also can serve as a final checklist for the SLP to ensure that all the criteria have been addressed.

Lewis Golinker is an attorney with 29 years experience in expanding access to funding for SGDs and currently serves as the advocacy director for the United States Society for Augmentative and Alternative Communication (USSAAC).  In the United States, he has worked to ensure SGD funding by Medicaid programs throughout the country, Medicare, Tricare and insurers.

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