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Funding Terminology

Funding Terminology

Throughout the funding process, you will be introduced to many different terms and acronyms that may seem like a foreign language for those of us who are new to the process. So, it is important that we get up to speed with what these terms mean. In fact, using the correct terminology throughout the funding documentation will actually expedite the success of the funding request as well. 

 

For educational purposes and to accelerate the overall funding process, FRS has generated the following term definitions. Please refer to these terms and definitions when reviewing and completing funding documentation. 

 

 

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Appeal

An appeal is the process, which occurs if the funding source denies a request for Prior Authorization/Pre‐determination. An appeal can also transpire from a denied claim. 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 as a result of using the appeal process.

 

Claim

The Claim is the billing process regulated by Forbes Rehab Services, Inc. Claims are submitted by FRS, Inc. to Medicaid, Commercial and Private Insurance Companies, HMO's, and CHAMPUS upon the equipment being supplied to the client.

 

Client Advocate

Typically the Client Advocate is 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 FRS, Inc. The Client Advocate is in close contact with the Funding Coordinator at Forbes Rehab Services.

 

Client Information Form

The Client Information form is a starting point for any funding packet. It gathers client information required by the funding sources.

 

Diagnosis

The diagnosis is the nature of the client’s disability. Examples include: Cerebral Palsy, Developmental Delay, Spastic Quadriplegia, Autism, etc.

 

Durable Medical Equipment (DME)

Durable Medical Equipment is a categorical term used by various funding sources, which often includes augmentative communication devices. This category usually includes but is not limited to: has 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.

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Funding Check List

This document is the final check prior to submittal of a funding request. Please make sure all of the required documents and information noted on the check list are included with the submittal.

 

Funding Coordinator

This is 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, Commercial and Private Insurances.

 

Funding Packet

The Funding Packet is a collection of all of the required documentation that is required by the funding source. A completed Funding Packet will have all of the Standard Forms listed in the Funding Downloads section, as well as the Speech Evaluation Report written by the 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

 

ICD Codes

ICD codes are the supporting Codes of Diagnosis.

 

Medicaid/Medical Assistance

This is 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.

 

Medical Necessity

There is no one definition for Medical Necessity. In short, the requested Speech Generating Device must treat the identified condition of the severe communication disability. Thus, the equipment should be justified in terms of a goal to overcome and or reduce the expressive communication limitation.

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Pre‐Determination of Benefits

Pre-determination of benefits is essentially the same process as Prior Authorization. It is specific to Commercial and Private Insurance Companies/HMO's such as Blue Cross/Blue Shield, Aetna, Anthem, etc. Some insurance companies will not do a pre‐determination of benefits and will request a Claim be filed; therefore, FRS, Inc. would require pre‐payment of the requested SGD/DME prior to ordering of the equipment.

 

Primary Insurance

Primary Insurance is 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.

 

Prior Authorization

Prior Authorization is 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. The Prior Authorization may be approved, denied or deferred for more information. The decision is based on specific regulations set by the funding source. Most funding sources lean towards the medical necessity of the equipment requested, but will vary. Prior Authorization as well as required co‐payments must be obtained before the requested DME can be supplied for the client.

 

Secondary Insurance

Second Insurance is 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 speech generating device is a device, which enables a client to overcome the disabling effects of communication impairment by representation of vocabulary or ideas and expression of messages.

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