FORMULA INTEGRATED TRAINING & THERAPY LLC is an out-of-network provider, meaning we do not participate with any insurance companies. If, on your own, you would like to pursue reimbursement from your insurance company, we have listed some questions to ask. You may already know the answers to some questions and not all the questions may apply to you.
To start, call the number on the back of your insurance card assigned to member services or something similar, and select the option to speak with a customer service representative. The answers will help you determine the potential for being reimbursed. Write down the person’s name in case you need to speak with him/her at a later date:
• What are your physical therapy benefits?
These benefits could fall under the category of “rehabilitation benefits” and may also include occupational therapy, speech therapy or massage therapy.
• Explain to the customer service provider that you are seeing a non-preferred, out-of-network provider and ask what is your out-of-network percentage of coverage?
• Ask if you have a deductible.
• If yes, how much is it?
• How much of the deductible have you met this year?
• Do you need a written referral from a doctor?
• Does the referral need to come from your primary care doctor?
• Do you need pre-authorization on file prior to starting physical therapy?
• If yes, is authorization on file already?
• Is there a special form you need to get reimbursed?
• If yes, where can you find the form?
• To what mailing address should the form be sent?
• Allow at least a week for the insurance company to process the form before your initial PT appointment.
• What is your percentage of reimbursement?
• Will the reimbursement rate change because you are seeing an out-of-network provider?
• Is there a limit on the total dollar reimbursement amount or a limit on the number of visits covered per year?
How to interpret the information you receive:
If your insurance company requires a pre-authorization or a doctor's referral on file and they don't have one, you will need to call your doctor's office. Ask them to file a referral for your physical therapy treatment that is dated to cover your first physical therapy visit. Keep in mind that pre-authorizations and referrals have an expiration date and some have a set limit on the number of visits. If you are approaching the expiration date or your visit limit, you will need to ask your doctor's office to submit a request for more treatments. If your insurance company requires a prescription from your doctor, you must send it in with your claim. Likewise, each time you receive an updated prescription, you must include it with your claim.
You need to meet your deductible before the insurance company will pay for your treatment. Make sure you submit all your bills to help you reach your deductible amount. If you have an office visit co-pay, the insurance company will subtract the amount from the reimbursement you will receive. The reimbursement will be based on your insurance company's “reasonable and customary fair price” for service codes rendered. This price might be different, either less or more, from the charges billed.
The following websites contain further information regarding reimbursement:
Please note: Medicare does not reimburse for out-of- network provider. This informational guide was created to help you to receive reimbursement for physical therapy services, but it does not guarantee reimbursement.