How to Determine Your Insurance Benefits for Physical Therapy


1

Call the toll free # 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 rehabilitation 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.

What You need to know:

  • Do you have a deductible? Yes/No If yes, how much is it? ___
  • How much has already been met? ___
  • What percentage of reimbursement do you have? (60%, 80%, 90%, are all common) _____
  • Does the rate of reimbursement change because you’re seeing a non-preferred provider? Yes/No
  • Does your policy require a written prescription from your primary care physician? Yes/No
  • If yes, will a written prescription from any MD/physician, or a specialist your PCP (primary care physician) referred you to be accepted? Yes/No
  • Does your policy require pre-authorization or a referral on file for outpatient physical therapy services? Yes/No
  • If yes, do they have one on file? Yes/No
  • Is there a $ or visit limit per year? Yes/No If Yes, What is it? ______
  • Do you require a special form to be filled out to submit a claim? Yes/No How do I obtain it? • What is the mailing address you should submit claims/reimbursement forms to?
  • Is there an online website where you can submit the claim? Yes/No What is the address?
4

What this information means:

  • A deductible must be satisfied before the insurance company will pay for therapy treatment. Submit all bills 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, some may be more.
  • If your policy requires a prescription or referral from your PCP you must obtain one to send in with the claim. This is usually not difficult to obtain if your PCP sent you to a specialist for help with your condition. If the referral 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 referral 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.

Please contact us if you have any further questions or would like help understanding your benefits. KEEP THIS WORKSHEET FOR YOUR RECORDS