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. 

  1. Call the toll free customer service number on the back of your insurance card. Jot this information:
    1. Name of Representative
    2. 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 

    1. If yes, how much is it? 
    2. 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?

 

Thank you for choosing MovEvolution. 

Excellent choice!