We have generated these term definitions because using the correct terminology throughout the funding process will expedite the success of your funding request. Please refer to these terms and definitions when reviewing and completing funding documentation.
The process which occurs if the funding source denies a request for prior authorization or pre‐determination, or if a claim is denied. The client advocate is responsible for initiating the appeal process. In most appeals, clarifying documentation is the key to success. There is usually a time limit in which an appeal can be filed. Multiple appeals may be filed for one client, and legal action against the funding source is often necessary for success. Many cases are funded by using the appeal process.
The billing process regulated by Forbes Rehab Services, Inc. Claims are submitted by Forbes Rehab Services, Inc. to Medicaid, commercial and private insurance companies, HMO's and CHAMPUS upon the equipment being supplied to the client.
Typically a speech-language pathologist or case manager. This person coordinates all necessary information and documents on the client’s behalf and submits the funding request to Forbes Rehab Services, Inc. The client advocate is in close contact with the funding coordinator at Forbes AAC.
Client Information Form
A starting point for any funding packet that gathers client information required by the funding sources.
The nature of the client’s disability. Examples include cerebral palsy, developmental delay, spastic quadriplegia and Autism.
Durable Medical Equipment (DME)
A categorical term used by various funding sources, often including augmentative communication devices. This label usually means the equipment has the ability to withstand repeated use, is provided to correct or accommodate a physiological disorder or physical condition, and is suitable for use in the recipient’s home.
The final check prior to submittal of a funding request. Please make sure all of the required documents and information noted on the checklist are included with the submittal.
The resource person from Forbes Rehab Services, Inc. who provides assistance and guidance throughout the funding process. The Funding Coordinator is responsible for submitting the necessary paperwork to Medicaid/Medical Assistance or commercial or private insurance companies.
A collection of all of the documentation required by the funding source. A completed funding packet will include all of the standard forms listed in the funding downloads section and a speech evaluation report written by a speech language pathologist. Because requirements may vary between funding sources, we recommend you contact our funding department for a complete list of all the required documentation
Codes from the International Classification of Disease. This includes codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
A public benefit program which is funded by federal and state governments. It provides medical assistance to persons with limited income and persons with disabilities. It is the largest and most important source of funding for speech generating devices. Medicaid policies vary from state to state.
A legal doctrine stating that the requested speech generating device must treat the identified condition of the communication disability. The equipment should be justified in terms of a goal to overcome and/or reduce the communication limitation.
The process in which the funding source, specifically Medicaid. reviews the required documentation gathered by the client advocate supporting the need for the requested speech generating device. Prior authorization may be approved, denied or deferred for more information based on specific regulations set by the funding source. Most funding sources focus on the medical necessity of the equipment requested. Prior authorization and required co‐payments must be obtained before the requested DME can be supplied for the client.
Pre‐Determination of Benefits
Essentially the same process as prior authorization, but is specific to commercial and private insurance companies and HMO's such as Blue Cross/Blue Shield, Aetna and Anthem. Some insurance companies will not do a pre‐determination of benefits and will request that a claim be filed, in which case Forbes AAC, Inc. would require pre‐payment of the requested SGD/DME prior to ordering the equipment.
The first funding source that must be used to secure funding. An insurance decision must be received prior to pursuing Medicaid funding for a speech generating device.
The secondary coverage source when an authorization or claim is denied or only partial funding has been secured from the primary insurance.
Speech Generating Device (SGD)
A device which enables a client to overcome the disabling effects of communication impairment by representation of vocabulary or ideas and expression of messages.