How to Determine Your Insurance Benefits for Physical Therapy
1. Call the 1-800 # for customer service on your insurance card. Select the option that will allow you to speak with a customer service provider, not an automated system.
2. Ask the customer service provider to quote your physical therapy benefits in general. These are frequently termed rehab benefits and can include occupational therapy, speech therapy, and sometimes massage therapy.
3. Make sure the customer service provider understands you are seeing a non-preferred provider/out of network provider who your doctor referred you.
What YOU need to know:
· Do you have an OUT OF NETWORK deductible? _______ If so, how much is it? ____________
· How much of the deductible has already met? __________
· What percentage of reimbursement do you have after the deductible is met? (60%, 80%, 90%, are all common) __________
· Does your policy require a written prescription from your primary care physician? ______________
· Does your policy require pre-authorization or a referral on file for outpatient physical therapy services? ____________
· How many physical therapy visits are allowed per year? ___________
· Is the plan based on a calendar year? ________If not, what are the plan dates? _______________________
· Are there any exclusions to my plan? (sometimes TMJ is not considered a medical covered benefit) ____________________
What this information means:
- A deductible must be satisfied before the insurance company will pay for therapy treatment. We will submit all payments to help reach the deductible amount.
- If you have an office visit co-pay the insurance company will subtract that amount from the percentage they will pay. This will affect the amount of reimbursement you will receive.
- The reimbursement percentage will be based on your insurance company’s established “reasonable and customary/fair price” for the service codes rendered. This price will not necessarily match the charges billed. Some may be less than you have paid.
- If your policy requires a prescription from your PCP you must obtain one to send in with the claim. This is usually not difficult to obtain since your PCP sent you to a specialist for help with your condition. If the prescription from a MD or specialist is all you need, make sure to have a copy to include with your claim. Each time you receive an updated prescription you’ll need to include it with the claim.
- If your policy requires pre-authorization or a referral on file and the insurance company doesn’t have one listed yet, you’ll need to call the referral coordinator at your PCP’s office. Ask them to file a referral for your physical therapy treatment that is dated to cover your first physical therapy visit. Be aware that referrals and pre-authorizations have an expiration date and some set a visit limit. If you are approaching the expiration date or visit limit you’ll need the referral coordinator to submit a request for more treatment.
This worksheet was created to assist you in obtaining reimbursement for physical therapy services and is not a guarantee of reimbursement to you.