Steps to Determine Out of Network (OON) Therapy Benefits

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. Let the customer service provider know that you are seeing an out-of-network (OON) or non preferred provider. Ask the customer service representative to quote your OUTPATIENT, OUT-OF-NETWORK Physical Therapy benefits.

3. Ask the questions below to obtain the most information possible to guide your decision

 

Questions to ask the Customer Service Representative: 

Name of Representative: _______________ Date/Time: ________________ 

1. Do I have Out-of-Network Benefits for Outpatient Physical Therapy? Yes ☐ No ☐ 

2.  Do I have a deductible? Yes ☐ No ☐ 

   1. If yes, how much is it? _________

   2. How much has already been met? _______ 

3. Do I have a per calendar year plan or a per benefit year plan? Yes ☐ No ☐ 

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

4. What percentage of reimbursement do you have for Out of Network Physical Therapy? (common ones are 50%, 60%, 80%) _________%

   1. Is that reimbursement rate based on the fee charged, or is it based on a rate set up by the insurance company?

5. Does my policy require a written referral/prescription from a primary care physician (PCP) or is a MD/PA/NP or specialist accepted?  Yes ☐ No ☐ Note: Rhode Island is a direct access state

6. Does my policy require pre-authorization or a referral on file for outpatient physical therapy services?      Yes ☐ No ☐ 

   1. If yes, do they have one on file? _________________

   2. What is the expiration date? _____________________ 

   3. Is there a “dollar amount” or “visit limit” per year?If yes, what is it? _______________ 

7. Do you require a special form to be filled out to submit a claim or can it be done online? Yes ☐ No ☐

8. What is the mailing address/website to submit to? ______________________________________

 

What this information means: 

Deductible: A deductible must be satisfied before the insurance company will pay for therapy treatment. Submit all bills to help reach the deductible amount.  

Co-Pay: 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.  

Reimbursement: 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. 

Referral or Prescription: If your policy requires a referral or prescription 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.  

Pre-Authorization: If your policy requires pre-authorization and the insurance company doesn’t have one listed yet, call your provider’s office and ask them for a referral for your physical therapy treatment that is dated to cover your first physical therapy visit. Be aware: referrals + pre-authorizations have an expiration date and/or a visit limit.

 

This information is provided to assist you in obtaining reimbursement for OON PT services and is not a guarantee of reimbursement to you. Obtaining reimbursement is the sole responsibility of the patient.

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