Understanding Your Out-of-Network Physical Therapy Benefits

Step 1: Contact Your Insurance Company

Call the toll-free customer service number on your insurance card and ask to speak with a live representative (not an automated system).

It can be helpful to write down:

  • Name of the representative

  • Date and time of the call

Step 2: Ask About Your Physical Therapy Benefits

Ask the representative to explain your physical therapy benefits, which may be listed under “rehabilitation services.” These benefits often include:

  • Physical therapy

  • Occupational therapy

  • Speech therapy

  • Sometimes massage therapy

Be sure to clarify that you are seeing a non-preferred / out-of-network provider.

Step 3: Key Questions to Ask

1. Deductible & Reimbursement

  • Do I have a deductible?

    • If yes, how much is it?

    • How much has already been met?

  • What percentage of reimbursement do I have for out-of-network care?
    (Common percentages include 60%, 70%, 80%, or 90%)

  • Does my reimbursement rate change because the provider is out-of-network?

2. Referrals, Prescriptions & Authorization

  • Do I need a written prescription for reimbursement for outpatient physical therapy services?

    • If yes, can it come from any physician or a specialist?

  • Are there visit limits or dollar limits per year?

3. Submitting Claims

  • Do I need a specific claim form to submit for reimbursement?

    • If yes, how do I obtain it?

  • Where should claims be mailed?

  • Is there an online portal where claims can be submitted?

What This Information Means

  • Deductible:
    Your deductible must be met before insurance contributes toward reimbursement. Submitting all physical therapy claims helps you work toward meeting it.

  • Reimbursement Amount:
    Insurance companies reimburse based on their own “reasonable and customary” rate—not the clinic’s billed rate. This amount may be lower or higher than what you paid.

  • Copays:
    If your plan includes an office visit copay, this may be subtracted from the reimbursement amount.

  • Referrals & Authorizations:
    If required, referrals or pre-authorizations must be active and valid for the dates of service. These may expire or have visit limits, so additional authorization may be needed over time.

Important Notes

  • Reimbursement is determined solely by your insurance plan and is not guaranteed.

  • Requirements vary significantly between plans—even within the same insurance company.

  • I am happy to provide itemized receipts (superbills) to support your claim submission.

I’m Here to Help

If you have questions about this process or would like help understanding what your insurance representative told you, please don’t hesitate to reach out.

This guide is meant to support you—not overwhelm you.

This resource is provided for educational purposes only and does not guarantee reimbursement.