Insurance Benefits Worksheet
Want to get the right answers from your insurance company?
Ask the right questions!
This worksheet was created to help determine your physical therapy out-of-network coverage.
Follow these steps to getting the information you need to plan your healing journey with us.
- Call the toll free customer service number on the back of your insurance card. Jot this information:
- Name of Representative
- Date of call
2. Ask the representative to quote your physical therapy benefits.
3. Make sure the representative understands you are seeing an “out-of-network provider.”
4. Ask if you have a deductible? Yes / No
- If yes, how much is it?
- If, yes, how much has already been met?
5. What % of reimbursement do you have? (60%, 80%, 90%, are all common.)
6. Does the rate of reimbursement change because you are seeing a non-preferred provided? Yes/No
7. Do you have a limit for the number of visits allowed? Yes/No. How many?
8. Does your policy require a written prescription? Yes / No. If yes, will you accept a written prescription from any MD/physician or specialist? Yes / No
9. Does your policy require pre-authorization or a referral on file for outpatient physical therapy services? Yes / No
10. Is there a limit on visits per year or per individual diagnosis? Yes / No If “yes”, what is it?
11. Do you require a special form to be filled out to submit a claim? Yes / No If yes, how do I obtain it?
12. What email or mailing address should I use when submitting claims/reimbursement forms?
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