Self-Insured: Medical Coverage and Marriage Counseling

CM_D

My company has a self-insured plan and I am the administrator on the plan. I have recently been questioned by an employee as to how to code marriage counseling so that it will be covered by insurance - can any of you tell me if you cover marriage counseling under your health plan?

Betty I_O

Marriage counseling would be covered in our plan if the provider meets certain criteria. In order to qualify for payment, the provider must be a licensed independent clinical social worker (LICSW), psychologist (PhD), psychiatrist (MD), or licensed mental health counselor (LMHC). The counseling benefit is 100% after a $10 co-pay and is limited to 25 visits during the calendar year.

irenesmsaclaims

Many plans exclude marriage/family counseling. Check your plan document exclusions. It sounds like this employee is asking you for tips on how to file a fraudulent claim. Sometimes providers will code something with a different code to ensure that the claim is paid when it shouldn't have been.

CM_D

I just got verification from my TPA that it is not covered. I just wondered if anyone else did cover it.