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 or 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 it?___________
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.