Out of Network Worksheet

How to Determine Your Insurance Benefits for Physical Therapy 

  1. Call the 1-800 # for customer service on the back of 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 
  4. If your doctor has referred you, tell the customer service provider this information. 

What YOU need to know: 

  • Do you have a deductible? If so, how much is it? How much is already met? 
  • What percentage of reimbursement do you have? (60%, 80%, 90%, are all common amounts) 
  • Does the rate of reimbursement change because you’re seeing a non-preferred provider? 
  • Does your policy cover telehealth at the same rates as in-person care?
  • Does your policy require pre-authorization, or to have a referral on file for outpatient physical therapy services?
    **Note that Washington state is a direct access state for physical therapy services, meaning you should not be required to get a written prescription. 
  • If yes, do they have one on file?
  • Is there a dollar ($) or visit limit per year? 
  • Does your policy reimburse for all common physical therapy codes used? Each code is billed at $50 per unit of 15 minutes, all follow up appointments are typically one hour or 4 units.

Therapeutic Exercise 97110-59 
Neuromuscular Re-education 97112-59 
Manual Therapy 97140 
Therapeutic Activity 97530-59 

  • What is the mailing address you should submit claims/ reimbursement forms to? 
  • Is there an option to submit claims/ reimbursement forms online?

 

We wrote this information to aid you in obtaining reimbursement for Physical Therapy services and is not a guarantee of reimbursement to you. 

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 pre-authorization, or a referral on file (see also next bullet point), 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 . 
  • 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