How To Determine Your Insurance Benefits For Physical Therapy
-Follow the steps below to navigate the Member Services system in order to understand and utilize your full benefit package.
-For your convenience, you can print this Insurance Benefits Worksheet to help guide you when contacting your insurance company.
-For your convenience, you can print this Insurance Benefits Worksheet to help guide you when contacting your insurance company.
1. Call the toll free # listed on your insurance card for Customer Service. Select the option to speak to a customer service
representative and avoid the automated system. You may have to input some of your identifying information first before
reaching the representative option.
2. Ask the representative (Name of Representative:_________________________) to provide you with the details of both your out-of-
network and in-network benefits for physical therapy. This may be lumped together with occupational and speech therapy as
well.
3a. Make sure you can answer the following questions for your Out-Of-Network Benefits:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
-Fax Number:____________________________________________________________________
3b. Make sure you can answer the following questions for your In-Network Benefits:
4. What this all means to you:
-97164, Physical Therapy Re-Evaluation: $_______________
-97110, Therapeutic Exercise: $_______________
-97112, Neuromuscular Re-education: $_______________
-97116, Gait Training: $_______________
-97140, Manual Therapy: $_______________
-G0283, Electric Stimulation (Unattended): $_______________
This worksheet was created to assist you in obtaining reimbursement for PT services and is not a guarantee of reimbursement to you. In addition, please note that this worksheet may not address every detail of your plan as all insurance plans are not the same.
Please do not hesitate to contact Dr. Greg Cecere if you have any further questions or would like assistance understanding your benefits.
representative and avoid the automated system. You may have to input some of your identifying information first before
reaching the representative option.
2. Ask the representative (Name of Representative:_________________________) to provide you with the details of both your out-of-
network and in-network benefits for physical therapy. This may be lumped together with occupational and speech therapy as
well.
3a. Make sure you can answer the following questions for your Out-Of-Network Benefits:
- Do you have a deductible? Y/N How much? (Individual/Family) $_______________
- How much has been met? (Individual/Family) $_______________
- What percentage of reimbursement do you have? (50%, 70%, 80%, etc.) __________%
- Is there an out-of-pocket expense limit? Y/N If yes, what is it? $__________________
- Is there a $ or visit limit per year? Y/N If yes, what is it? __________________________
- Does your policy require a written prescription from your Primary Care Physician (PCP) or a specialist that your PCP referred you to? Y/N
- Does your policy require preauthorization or a prescription on file for outpatient physical therapy services? Y/N
- Is there a special form to be filled out to submit a claim? Y/N
- What is the mailing address to submit claims/reimbursement forms?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
- Is there an online website or fax number to submit claims/reimbursement forms?
-Fax Number:____________________________________________________________________
3b. Make sure you can answer the following questions for your In-Network Benefits:
- Do you have a deductible? Y/N How much? (Individual/Family) $________________
- How much has been met? (Individual/Family) $________________
- Do you have a co-pay? Y/N If yes, how much is it? $______________________________
- Do you have a coinsurance split? Y/N If yes, what is it? ___________________________
- Is there an out-of-pocket expense limit? Y/N If yes, what is it? $___________________
- Is there a $ or visit limit per year? Y/N If yes, what is it? ___________________________
- Does your policy require a written prescription from your Primary Care Physician (PCP) or a specialist that your PCP referred you to? Y/N
- Does your policy require preauthorization or a prescription on file for outpatient physical therapy services? Y/N
4. What this all means to you:
- A deductible must be satisfied before the insurance company will pay/reimburse for physical therapy treatment. Submit all bills to help reach the deductible amount.
- The reimbursement percentage will most likely be based upon your insurance company’s established “reasonable and customary/fair price” or "allowable amount" for the service codes rendered. This price will not necessarily match the charges billed; some may be less, some may be more. In order to determine the "fair price" or "allowable amount," you can request the price for the following codes which are the most common codes used at Momentum Physical Therapy of New Paltz.
-97164, Physical Therapy Re-Evaluation: $_______________
-97110, Therapeutic Exercise: $_______________
-97112, Neuromuscular Re-education: $_______________
-97116, Gait Training: $_______________
-97140, Manual Therapy: $_______________
-G0283, Electric Stimulation (Unattended): $_______________
- 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.
- If your policy requires a prescription from your PCP or a specialist, you must obtain one to send a copy in with your claim. This is usually not difficult to obtain if you already saw your PCP or were referred to a specialist. Each time you receive an updated prescription you will need to include a copy with your claim.
- If your policy requires preauthorization or a prescription on file and the insurance company does not have one listed yet, you will need to call the referral coordinator at your PCP or specialist's office. Ask them to file a prescription for your physical therapy treatment that is dated to cover your first physical therapy visit. Be aware that prescriptions and preauthorizations have an expiration date and some set a visit limit. If you are approaching the expiration date or visit limit you will need the referral coordinator to submit a request for more treatment.
This worksheet was created to assist you in obtaining reimbursement for PT services and is not a guarantee of reimbursement to you. In addition, please note that this worksheet may not address every detail of your plan as all insurance plans are not the same.
Please do not hesitate to contact Dr. Greg Cecere if you have any further questions or would like assistance understanding your benefits.
KEEP THIS WORKSHEET FOR YOUR RECORDS
