Use this worksheet when calling your insurance company to inquire about your benefits. This should assist you in determining your eligibility for reimbursement for your visits and is not a guarantee of payment. We are happy to help you navigate this process, however, speaking to your insurance company directly is the only way to accurately determine these benefits.
Call the Customer Service phone number on the back of your insurance card and ask to speak to a representative. Tell them you are calling about your outpatient physical therapy benefits and how they compare to your in-network benefits. Ask the following list of questions.
- Can I see an out-of-network provider?
- How do I submit a claim for reimbursement? By mail? Online? ________
- What is my deductible? $________
- How much of my deductible is remaining? $________
- How much is my co-pay? $________
- What is my co-insurance? ________%
- Is there a visit limit or a dollar limit for physical therapy?
- Do I need a prescription or referral to see a physical therapist or can I self-refer?
- If I do need a prescription or referral, does my primary care physician (PCP) have to write it? If not, who can write it?
- Do I need pre-authorization for out-of-network physical therapy benefits? Yes/No
- If yes, how do I obtain this? ________
- Or, if pre-authorization is already on file, and what are its details (valid dates, visits approved, etc.)? ________
- What is my out-of-pocket limit/maximum? $________
- Do my benefits renew at the New Year or another time? If so, when?
Co-insurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Co-payment (aka co-pay): A fixed amount (for example, $30) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Deductible: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Out-of-network or Non-preferred provider: A provider who doesn’t have a contract with your health insurer or plan to provide services to you. Usually, you pay more to see a non-preferred provider, however, if you have not met your deductible, the cost may be comparable to seeing an in-network provider.
Out-of-pocket limit/maximum: The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. Some health insurance or plans don’t count your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover.
Pre-Authorization: A decision by your health insurer or plan that a health care service is medically necessary. Sometimes called prior authorization, prior approval or pre-certification. Your health insurance or plan may require pre-authorization for certain services before you receive them. Pre-authorization isn’t a promise your health insurance or plan will cover the cost.
Here is a helpful handout from the Centers for Medicare and Medicaid Services with additional terms defined.
Ready to reach your highest potential?
Click the Schedule Now button to take the next step towards optimizing your health and solving your concerns.