How do I find my occupational therapy insurance 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. Ask the customer service provider to quote your general occupational therapy benefits. These are often referred to as “rehabilitation benefits” and can include physical therapy, speech therapy, and sometimes massage therapy.
3. If you are planning on receiving telehealth/online OT, please ask (a) if telehealth is covered and (b) at what rate.
4. Ask if pre-authorization is required before treatment can begin.
5. Make sure the customer service provider understands you are seeing an out- of-network provider.
What YOU need to know:
• Do you have a deductible? Yes/No If yes, how much is it? ___ How much has already been met? ___
• What percentage of reimbursement do you have? (60%, 80%, 90%, are all common) _____
• Does the rate of reimbursement change because you’re seeing a non-preferred provider? Yes/No
• Does your policy require a written prescription from your primary care physician? Yes/No
• If yes, will a written prescription from any MD/physician, or a specialist your PCP (primary care physician) referred you to be accepted? Yes/No
• Does your policy require pre-authorization or a referral on file for outpatient occupational therapy services? Yes/No
• If yes, do they have one on file? Yes/No
• Is there a $ or visit limit per year? Yes/No If Yes, What is it? ______
• Do you require a special form to be filled out to submit a claim? Yes/No How do I obtain it?
• What is the mailing address you should submit claims/reimbursement forms to?
• Is there an online website where you can submit the claim? Yes/No What is the address?
4. What this information means:
• A deductible must be satisfied before the insurance company will pay for therapy treatment. Submit all bills to help reach the deductible amount.
• 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.
• If your policy requires a prescription or referral from your PCP you must obtain one to send in with the claim. This is usually not difficult to obtain if your PCP sent you to a specialist for help with your condition. If the referral from a MD or specialist is all you need, make sure to have a copy to include with your claim. Each time you receive an updated referral you’ll need to include it with the claim.
• If your policy requires pre-authorization or a referral on file and the insurance company doesn’t have one listed yet, you’ll need to call the referral coordinator at your PCP’s office. Ask them to file a referral for your occupational therapy treatment that is dated to cover your first occupational therapy visit. Be aware that referrals and pre-authorizations have an expiration date and some set a visit limit. If you are approaching the expiration date or visit limit you’ll need the referral coordinator to submit a request for more treatment.
This worksheet was created to assist you in obtaining reimbursement for occupational therapy services and is not a guarantee of reimbursement to you.
Please contact me if you have any further questions or would like help understanding your benefits.
KEEP THIS WORKSHEET FOR YOUR RECORDS.