Denials And Deferrals

Denials And Deferrals

Sometimes, a funding request does not end in a positive outcome. Your SLP, together with PRC's Funding Department, can work to get a decision overturned.

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Sometimes, a funding request doesn't have a desired result. Your SLP and PRC funding specialist can work together to try and overturn a denial, or get a positive outcome to a deferral.

Deferrals

What is a deferral?
A deferral is when the health insurance company holds off on making a decision on authorizing the request for a speech generating device because it needs more information.

When a deferral is received, it typically includes:

What happens when there’s a deferral?
Typically, the evaluating SLP will need to provide additional information to the evaluation that addresses the reason for deferral. He or she will work with the PRC funding specialist to ensure that they have the correct information to submit.

How long until we receive an answer?
Response times can vary. If PRC has submitted the deferral response and does not hear back from the health insurance company within 30 days, PRC will contact the health insurance company.

If someone else (SLP or another party) submitted the deferral response and has not heard back from the health insurance company within 30 days, they should contact the health insurance company.

Denials

What is a denial?
A denial is when the health insurance company makes the decision NOT to authorize payment for the requested speech generating device.

What can I do if our request is denied?
You and/or your SLP should have received a written/official denial from the health insurance provider.

A denial typically includes:

Your SLP will work with the PRC funding specialist to file an appeal.

If you did not receive a denial in writing, then your SLP will work with the PRC funding specialist to call, email or fax the health insurance company to request a written/formal denial.

For private insurance appeals, PRC is often not permitted to file the appeal paperwork for you. For Medicaid and Medicare, PRC can, in most cases, but not all, file the appeal paperwork for you. Either way, your PRC funding specialist will assist your SLP in compiling information for an appeal.

What happens if we lose?
If the appeal is lost, and you’d like to continue to pursue funding, your SLP can contact the PRC funding department to discuss options and how PRC may be able to help with further appeal.





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