How to Determine Your Insurance Benefits for Physical Therapy

1. Call your insurance company. The customer service number is 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 “Physical Therapy” benefits in general. These are frequently termed rehabilitation benefits and can include PT, OT, SLP, and sometimes chiropractic.

You may need to ask for a specific CPT codes coverage: 

• Physical Therapy Evaluation: 97161 / 87162 / 97163

• Physical Therapy Treatments: 97530 / 97140 / 97112 / 97110 / 97116 / 95992 (if you have dizziness)

• Dry Needling: 20560 / 20561 state this would be performed by a physical therapist ; not often covered)

What you need to know:

• Insurance Company Primary:_________________________ 

• Name of customer service rep you are talking to:____________________________________________

• Call Reference Number:______________________________________________________________

• Do you have a deductible?______If so, how much is it?__________  How much is already met?___________

• What percentage of reimbursement / owe do you have? (60/40%, 80/20% are all common)_____________

• OR what co-pay do you have? ($25, $50 are all common) ______

• Does your policy require pre-authorization?______________________If yes with which company?_____________

• Is a referral on file required for physical therapy services?_____________________

• Is there limit on number of visits per year? _____________________  

• What CPT codes above are covered?__________________________________________________________

If you have a secondary insurance, please repeat these questions for your secondary insurance

• Insurance Company Primary:_________________________ 

• Name of customer service rep you are talking to:____________________________________________

• Call Reference Number:______________________________________________________________

• Do you have a deductible?______If so, how much is it?__________  How much is already met?___________

• What percentage of reimbursement / owe do you have? (60/40%, 80/20% are all common)_____________

• OR what co-pay do you have? ($25, $50 are all common) ______

• Does your policy require pre-authorization?______________________If yes with which company?_____________

• Is a referral on file required for physical therapy services?_____________________

• Is there limit on number of visits per year? _____________________  

• What CPT codes above are covered?__________________________________________________________

• A deductible must be satisfied before the insurance company will pay for therapy treatment. You may owe more money to satisfy the deductible.

• The reimbursement percentage will be based on your insurance company’s established allowed amounts or “reasonable and customary/fair price” for the service codes rendered. This price will not always match the charges billed. You can ask what the allowed amounts are but are not often disclosed by commercial insurance companies. Federal payers list their physician fee schedules online. 

This worksheet was created to assist you in understanding your therapy services and is not a guarantee that the insurance company will pay.  Charges not covered by your insurance company are your own responsibility to pay.