4.5 Guide to Benefits and Coverage

Before a client's first session, two things have to be true: their plan has to cover ABA for them, and you have to be able to bill that plan. Alpaca handles the heavy lifting, but knowing how it works means you can read a client's Care Readiness tab at a glance and never get caught off guard by a coverage problem.
This is a go-and-look step: open a client and find their Care Readiness tab. Nothing to fill out, just get familiar with where benefits live.

In-Network Status

In-network means you have a contracted rate with a payer. You become in-network through credentialing: the NPI and CAQH work, plus Alpaca driving the payer contract. Until that contract exists, you generally can't bill that payer.

You're in-network per payer, not per client. Once you're contracted with Colorado Medicaid, every Colorado Medicaid client you take is in-network. If a family's plan is one you're not contracted with, don't schedule against it and hope it works out. Reach out to Alpaca first. A single-case agreement sometimes exists, but it's arranged case by case.

Note: Matched referrals come to you for payers you can already bill. If something looks off, ask support before delivering services.

Verification of Benefits (VOB)

Before you're matched with a family, Alpaca's intake team runs a Verification of Benefits (VOB) with the client's insurance. VOB tells you whether ABA is covered and what it'll cost the family:

• Whether ABA is a covered benefit

• The family's cost-sharing (copay, coinsurance, and remaining deductible)

• What services and codes the plan will authorize

VOB data drives the platform's patient-responsibility estimates, which in turn drive your biweekly payout math (see Guide to Alpaca's Payout System). An accurate VOB protects your cash flow, it's not just paperwork.

Reading the VOB Status Card

On the client's Care Readiness tab, the Verification of Benefits card shows one of four statuses:

• Verified: VOB is complete; the benefit details shown are accurate.

• Pending: Alpaca is still running it.

• Incorrect: a detail needs fixing, often an insurance ID or member number. Alert Alpaca so we can update the card and re-run benefits. A wrong ID stalls VOB and, later, claims.

• Not started: VOB hasn't begun, usually because information is missing.

Note: You'll also see the insurance cards on file for the client. If a card is new, changed, missing, or unreadable, alert Alpaca. We update the card on file and re-run VOB for you, so the fastest way to unblock coverage is simply to flag the change.

Your Job: Alert Alpaca to Insurance Card Changes

You don't fix insurance details yourself. Your job is to tell Alpaca whenever a family's insurance changes: a new card, an updated plan, a corrected member ID, or a VOB showing "Incorrect." Alpaca updates the card on file and re-runs benefits. Flagging changes promptly is what keeps coverage and your payout math accurate.

Patient Responsibility: Copay, Coinsurance, Deductible

• Copay: a flat per-session amount. Alpaca applies it only to the first session per day per code, so families aren't double-charged when a client has two sessions in a day.

• Coinsurance: a percentage of the allowed amount the family pays.

• Deductible: what the family pays out of pocket before insurance starts paying. Early in a plan year, more cost falls on the family until the deductible is met.

Alpaca estimates these from VOB for your payout math, but families are never charged off that estimate. Once the insurer sends its final EOB for a claim, Alpaca bills the family through the parent portal for the amount the EOB says they owe. You don't chase payment, but you should be able to explain why a family's balance looks the way it does.

Coordination of Benefits (COB): When a Client Has Two Plans

Some clients carry two active insurances, for example a commercial plan and Medicaid. Coordination of benefits decides which pays first.

• Primary pays first; secondary picks up what primary leaves. Submit to the primary payer first.

• Medicaid is the payer of last resort. By law, Medicaid pays only after other coverage, so commercial-primary plus Medicaid-secondary means commercial is billed first.

• The exception that matters in ABA: if you already know the primary will deny ABA (for example, a commercial plan that won't cover it without a formal autism diagnosis on file) and the secondary will cover it, submit to the payer that will actually authorize and pay. Don't burn weeks on a guaranteed denial.

Note: When it's unclear which plan should carry a client, email support@alpacahealth.io before submitting.

Who Does What

Quick Reference

• Where: client profile → Care Readiness tab (VOB card, benefit details, insurance cards).

• In-network is per payer and comes from credentialing, not something you set per client.

• VOB (run by Alpaca) tells you if ABA is covered and what the family owes; watch for Incorrect or Not Started statuses.

• Your job on benefits: alert Alpaca to insurance card changes. Alpaca updates the card and re-runs VOB.

• Patient responsibility = copay + coinsurance + deductible, estimated from VOB.

• COB: primary bills first, Medicaid is last resort, but submit to whichever payer will actually authorize and pay.

• Authorizations, Care Readiness, units, and re-auth are covered in a separate guide.