INSURANCE REIMBURSEMENT
This information explains how you can find out whether you can get insurance reimbursement for physical therapy services, but is not a guarantee of reimbursement to you.
How to Find Out If Your Insurance Covers Physical Therapy With Us
If you have health insurance, you might be able to get reimbursed for what you spend on your physical therapy care with us. We do not work with Medicare or its supplemental but will work with secondary insurance (i.e., Advantage Plans) if you have Medicare. Every insurance policy is different, so the first step is finding out what your insurance benefits are for physical therapy.
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Getting Started – Contact Your Health Insurance Company
Call the toll free customer service number on the back of your insurance card. Select the option that allows you to speak to a customer service rep, not an automated attendant.
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Ask the customer service rep if you have out-of-network benefits for physical therapy. (We are considered an out-of-network provider by all insurance companies).
If they say "NO"
This means your insurance will not reimburse you for your physical therapy with us. This does not mean you can't have physical therapy; it just means your insurance will not reimburse you for what you spend for physical therapy at our office. If you have coverage for in-network physical therapy, to get reimbursement you would need to go to a provider in your insurance company's network. Ask your insurance company who those providers are in your area and what your co-pay is and what your co-insurance rate is for physical therapy services. Often, our fees are lower than what you pay out-of-pocket for physical therapy at an in-network provider. See how our fees compare to what you might pay at other providers.
If they say "YES", ask your customer service rep these questions:
What is my out-of-network deductible and how much has already been met?
This is the amount you are responsible for paying before the insurance company will start reimbursing you. The amount of your out-of-network deductible varies depending on your insurance policy and is different than your in-network deductible. Your insurance company will apply your claims to the deductible amount before you are eligible to receive reimbursement.
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What is the insurance company's “reasonable and customary price” for these procedure codes: 97140, 97110, and 97162?
These are the procedure codes used most often for our physical therapy services. Your reimbursement will be based on your insurance company's reasonable and customary price for the services you receive. The reasonable and customary prices the insurance company gives you will not necessarily match our prices; some may be less and some may be more.
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What is the percentage of reimbursement I will get for out-of-network physical therapy?
This is the percentage of the claim the insurance company will reimburse you for. The remaining amount is your "co-insurance" - the amount you are not reimbursed for. For example, a typical reimbursement/insurance ratio is 70/30 - this means the insurance company reimburses you 70 percent of your claim and your share (not reimbursed) is 30 percent. The percentages are applied either to the "reasonable and customary price" or to our fee, whichever amount is less.
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Does the insurance company require a special claim form and do I have to fill out a form for each claim?
This is usually on the insurance company’s website but the customer service representative can direct you on where to find the information.
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What is the mailing address to submit claims to?
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Do I need a physical therapy referral or doctor’s order from my primary care provider?
We are a direct access clinic, meaning we can see you without a referral from your physician but your insurance company may require one to reimburse you.
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Do I need to send in a copy of the initial physical therapy evaluation?
This is generally not required but we are happy to supply a copy if requested.
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Are copies of the therapy notes required for each claim?
This is generally not required but we are happy to supply a copy if requested.
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Submitting claims to your insurance company
When you receive physical therapy at our practice, you will pay for the service at the time of your visit and will be emailed a payment receipt. This payment receipt does NOT include the necessary information required by insurance companies for submitting a claim. You will need to let us know that you will be seeking reimbursement as paperwork is not automatically generated for patients.
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What We Provide
Superbill: generated after the therapist completes your visit notes, showing the following information:
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Your name and date of birth
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Our name, location and contact info
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Provider number
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Tax ID#
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Therapist name and license info
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Diagnosis code(s)
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CPT Codes and description of services provided
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Amount charged
Payment History: shows the fees you paid out of pocket when the services were provided , listing method of payment, date and amount
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The information needed for your claim will be included in this paperwork. These .pdf documents will be emailed to you and together, this is the paperwork you submit to your insurance company to seek reimbursement. You can upload them on insurance portals or print them to mail in.
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After you file your claim the insurance company should provide you with an EOB (explanation of benefits). This explains what they intend to pay towards your claim. The EOB is usually issued before any reimbursements are made.