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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.

What YOU need to know:

• Do you have an out-of-network deductible? _____ If so, how much is it? _____ How much is

already met? _____

• What percentage of reimbursement do you have? (commonly 60%, 80%, 90%) _____

• Does the rate of reimbursement change because you’re seeing a non-preferred provider? _____

• Does your policy require a written prescription from your primary care physician (PCP)?

_____

• Will a written prescription from any MD, or a specialist your PCP referred you to be accepted?

_____

• Does your policy require pre-authorization or a referral on file for outpatient physical therapy

services? _____

• If yes, do they have one on file? _____

• Is there a $ or visit limit per year? _____

• What is the mailing address you should submit claims/ reimbursement forms to? Can you

submit claims electronically?

__________________________________________________________

__________________________________________________________

__________________________________________________________

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What this information means:

• Typically a deductible must be satisfied before the insurance company will pay for therapy

treatment. Submit all bills (from all providers) 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 “usual

and customary rate” 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 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 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 will 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-auths 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.

KEEP THIS WORKSHEET FOR YOUR RECORDS