Call the member-services number on the back of your insurance card before your first visit.

You can begin by saying:

“I am considering outpatient Physical Therapy with an out-of-network provider. Can you explain my benefits and what I may be responsible for paying?”

Must Do

Ask these essential questions:

1. Is out-of-network Physical Therapy covered? Some plans do not provide out-of-network benefits for planned outpatient care.

2. What is my out-of-network deductible? How much have I already met? How much remains? Your out-of-network deductible may be separate from—and higher than—your in-network deductible.

3. Is reimbursement based on the provider’s fee or on the plan’s allowed amount? The allowed amount is the maximum amount your insurance company recognizes for a service. It may be lower than the provider’s actual fee.

4. Do I need a referral or prior authorization? These requirements come from your insurance plan and may apply even when state law allows you to see a Physical Therapist without a referral.

5. How many Physical Therapy visits are allowed? How many have I used? How many remain?

6. Will I owe charges above the allowed amount? You may be responsible for your remaining deductible, co-payment or co-insurance, the difference between the provider’s fee and the allowed amount, and any services the plan decides are not covered.

7. Is there an out-of-network out-of-pocket maximum? Do not assume every out-of-network expense will count toward your maximum.

8. How long do I have to file my claim? Ask for the exact deadline and whether it is measured from the date of service.

9. How do I submit the claim? Through the member portal, an insurance application, secure upload, fax or mail.

10. What is the representative’s name? What is the call reference number? Record the representative’s name, date and time, Call reference number. Keeping this information can help if you receive a different answer later.

At Therapeutic Connection Physical Therapy and Wellness, payment is collected at the time of service. You will receive an itemized receipt or superbill that you can submit to your insurance company.

Must Do

1. Obtain your itemized receipt or superbill. This will generally include:

• Provider information

• Date of service

• Diagnosis codes

• Treatment or procedure codes

• Amount charged

• Proof of payment

A superbill provides the information your insurance company needs to review the claim, but it does not guarantee reimbursement.

2. Complete your insurance company’s claim form

Some plans require a member medical-claim form in addition to the superbill.

The form may be available:

• In your online member portal

• On the insurance company’s website

• By calling member services

3. Submit the claim before the deadline

Send the completed claim form, superbill, and any other requested documents using the method provided by your plan.

4. Keep a copy

Save copies of:

• The completed claim form

• The superbill

• Any referral or authorization

• Supporting documents

• Proof that the claim was submitted

5. Confirm whether anything else is required

Your plan may also request:

• Proof of payment

• A physician referral

• Prior-authorization information

• Treatment notes or medical records

• A provider signature

• Additional provider information

6. Record how and when you submitted the claim

Save:

• Online confirmation numbers

• Upload receipts

• Fax confirmations

• Certified-mail receipts

• Screenshots from the member portal

7. Confirm who will receive reimbursement

When you pay the provider directly, reimbursement is sent to you. Ask whether payment will be issued:

• By check

• By electronic deposit

• Through another payment method

8. Follow the claim in your member portal. Check that the claim was received and is being processed.

9. Contact the insurance company if the claim does not appear after a reasonable processing period.

After processing your claim, your insurance company will send an Explanation of Benefits, commonly called an EOB.

An EOB is not a bill. It explains how the insurance company reviewed and processed your claim.

Must Do:

Review these five items:

1. Provider’s charge. This is the amount submitted for the service.

2. Allowed amount. This is the amount your insurance company recognizes for the service. The allowed amount may be lower than the provider’s actual fee.

3. Amount applied to your deductible. This shows how much of the allowed amount you were required to pay before insurance benefits applied.

4. Amount paid by the plan. This is the amount the insurance company paid or reimbursed.

5. Your responsibility

This may include:

• Deductible

• Co-payment

• Co-insurance

• Charges above the allowed amount

• Services the plan did not cover

Compare the EOB with the benefits information you received before treatment.

6. Look for adjustment or denial codes

The EOB should explain why a service was:

• Reduced

• Applied to the deductible

• Considered noncovered

• Denied

• Missing information

7. Make sure the claim was processed correctly

Check that:

• Your name and member information are correct

• The date of service is correct

• The provider and service information are correct

• Any referral or authorization was recognized

• The correct out-of-network benefits were applied

8. Contact your insurance company if something appears wrong.

Ask the representative to explain:

• Why the claim was reduced or denied

• Whether additional information is needed

• Whether the claim can be reprocessed

• How to request reconsideration or file an appeal

• The deadline for an appeal

9. Write down the representative’s name and the call reference number.

10. Keep your records. Save the EOB with your superbill, claim form, and proof of submission. These documents may be needed if you question the payment or appeal the decision.