How to Determine Your Insurance Benefits for Physical Therapy

KEEP THIS WORKSHEET FOR YOUR RECORDS

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, via direct access or for whom you have a doctor’s referral.

4. If pre-authorization or pre-certification is required, please allow one week to process BEFORE your initial consultation. Let our offices know immediately and whether a form is required to fill out.

A special note to patients with Medicare: Podium Physical Therapy & Performance Training does NOT accept Medicare and patients cannot be reimbursed by Medicare for visits at this clinic.

What YOU need to know:

• MOST IMPORTANT: Does your policy require pre-authorization or a referral on file for outpatient physical therapy services? ____
• Will a written prescription from any MD, or a specialist your PCP referred you to be accepted? _____
• 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) _____
• 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? _____
• If yes, do they have one on file? _____
• Is there a $ or visit limit per year? _____
• Do you require a special form to be filled out to submit a claim? _____
• What is the mailing address you should submit claims/ reimbursement forms to? _____

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What this information means: 

• 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.
• 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 fee you paid for services at Podium Physical Therapy & Performance Training. 
• 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 you accessed services via Direct Access, the physical therapist at Podium Physical Therapy & Performance Training will write a Letter of Medical Necessity, send it to your physician for their signature, and this is generally received by the insurance company as a physician's prescription or referral. 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.

This worksheet was created to assist you in obtaining reimbursement for physical therapy services and is not a guarantee of reimbursement to you.