Out of Network Billing

Determining your out of network benefits

KEEP THIS WORKSHEET FOR YOUR RECORDS

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 OUTPATIENT, OUT- OF- NETWORK physical therapy benefits. 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, out-of-network provider who your doctor referred you to.

Questions to ask the customer service representative

Representative name:
Date/time:

1. Do I have Out-of-Network Benefits for Outpatient Physical Therapy? Yes / No
2. Do I have a deductible? Yes / No
   a. If yes, how much is it?

b. How much has already been met?

c. Do I have a per calendar year plan or a per benefit year plan?

d. If per benefit year, what are my dates of coverage?

4. What percentage of coverage is my responsibility for seeing an OON provider?

5. Does my policy require a written referral or prescription? Yes / No

a. If yes, a written prescription from ANY prescribing provider?(eg: physician, nurse

practitioner, podiatrist, chiropractor) Yes / No

b. If no, does it have to come from a PCP (primary care provider)? Yes / No

i. What is the name of the PCP on file?

ii.

6. Is pre-authorization required for physical therapy services? Yes / No

a. If yes, do I have one on file? Yes / No

b. What is the expiration date?

7. Is there dollar amount or visit limit per year? Yes / No

a. If yes:

Dollar amount? Visit limit

8. Do I require a special form to submit a claim? Yes / No

a. If yes, how can I obtain it?

9. What is the mailing address where I should send claims/ reimbursement forms?

10. Can I submit my claim on-line? Yes /No

a. How?

Insurance, whether it is in-network or out-of-network, can be confusing and tricky to deal with. We will

try our best to guide you along the way. Here is some other helpful information.

Please understand, this worksheet was created to assist you in obtaining reimbursement for Physical

Therapy services and is not a guarantee of reimbursement to you.

• 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 a provider you must obtain one to send in

with the claim. Each time you receive an updated referral you’ll need to include it with the

claim.

• If your policy requires pre-authorization and the insurance company doesn’t have one listed yet,

you’ll need to call the referral coordinator at your provider’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.