The following 3 documents are required for In-Network clients only: (not applicable to out-of-network or non-insurance clients)

1. Prescription from your child’s diagnosing Neurologist or Pediatrician

**Must be written on the Prescription**

1. “Occupational Therapy Treatment"

2. ICD-10 Diagnostic Numeric Code (please only use appropriate medical necessity based codes related to the child's need for therapy). Avoid using all developmental diagnostic codes, i.e.  ADHD, PDD, Sensory Integration Disorder, or Developmental Delay/Disorder, as these codes, as well as other similiar ICD-10 codes, are usually not accepted by the insurance companies. 

3. Descriptive Name of the ICD-10 Code.

 As of 10/1/2015 ICD-9 codes will not be accepted.

Note:  Jason's Sensory Gym will NOT accept ICD-10 codes that are not applicable to your child or supply a parent/doctor with a diagnostic code. Insured policy holder must call their insurance provider, as Jason's Sensory Gym is not responsible for verifying if ICD-10 codes are payable by your insurance plan.

OXFORD members - Diagnosis must be due to a disease, surgery to correct a congenital deformity, or injury.  Coverage is based your certificate of benefits.  Please call Oxford to verify coverage. 

 **AND**

      2.  “Letter of Medical Necessity”– Must be written on doctor’s letterhead

      A letter from your child’s physician stating: 1) your child’s diagnosis is a neurologically based condition and not developmental in nature, and 2) your child’s diagnosis requires medically based occupational therapy treatment due to whatever concerns you and your pediatrician have about your child.

Note:  If your insurance plan does not require pre-authorization (different from a referral) for occupational therapy, then the letter of medical necessity is not necessary.  Please call your insurance company to find out if pre-authorization is required.

**AND**

      3.  Occupational Therapy Evaluation Report with long term and short term goals/objectives.  A current comprehensive evaluation report (not a progress report or an IEP page) signed by a licensed occupational therapist is needed only if pre-authorization is required for occupational therapy treatment.  Date of Evaluation must be within a month.

Please Note:

1.  Your insurance company will only reimburse for medically based occupational therapy services and not for school-based developmental conditions.  Your insurance company uses a medical model and will deny claims based on a school-based developmental model.  Therefore, your physician must present your child’s occupational therapy needs as a medical necessity.

2.  All original documents must be given to Jason’s Sensory Gym on or before the treatment day. Treatment will not be performed without these documents.  Take a photo of the Rx and email it to adlxprt@yahoo.com.  Make sure your child's name, member ID number, and birthday is written on each document. 

3.  These documents are not a guarantee of approval from your insurance company for occupational therapy treatment. 

4.  Jason’s Sensory Gym will not be held responsible for receiving incorrect information given by the insurance representative when obtaining in-network occupational therapy benefits.  Insured must contact their insurance provider to verify occupational therapy office visit benefits (including referral, authorization, deductible, visit limits, & copay) prior to the first appointment.  Insured will also be responsible for tracking session limitations allotted by their insurance plan.