Out-Of-Network Reimbursement Guide

1. Call the toll free # for customer service on your insurance card.
2. Select the option that will allow you to speak with a customer service provider (NOT an automated system).  
   1. Tip: If you do not hear an option to speak with a customer service representative, you may try pressing the number “0” which often transfers you to a live person or operator.  

Ask the customer service provider to quote your physical therapy benefits in general.  These are frequently termed “rehabilitation” benefits and can include occupational therapy, speech therapy, and sometimes massage therapy.

“Do I have out-of-network benefits for outpatient physical therapy?  Do I have coverage when seeing a non-preferred out-of-network physical therapy provider?”  (YES / NO)

• If no:
  • You will not receive reimbursement from your insurance company for physical therapy services with Convergent Movement and Performance. This however does not prevent you from receiving services from Convergent Movement and Performance.  
• If yes:
  • Continue to Step 4

Note: This step (Step 4) is only required if you wish to seek reimbursement for services performed outside of the ‘1200 US Highway 22 East, Suite 2000, Bridgewater, NJ 08807’ or ‘223 Stirling Rd, Warren, NJ 07059’ locations.

This includes telehealth.

Convergent Movement and Performance offers specialized services for select cases where Dr. Ketselman is able to travel to your home, gym/fitness facility, sporting practice or event, or place of work to provide “in action” and on-site services and care. 

We also provide telehealth services.   

Unfortunately, insurance companies do not always reimburse services provided outside of the outpatient clinic.  Therefore, please be sure to check with you insurance provider prior to starting services if you hope to be reimbursed.  

1. “Are there any limitations on where I can be seen for physical therapy services and still receive out-of-network reimbursement?” (YES/NO)
2. ”In addition to being seen in an outpatient clinic, am I able to receive reimbursement if seen:
   1. Through telehealth (Yes/No)
   2. Within my own home (Yes / No)
   3. At my place of employment (Yes / No)”
   4. *Any other location you choose (Yes/No)

For Telehealth:

1. “Is live video PHYSICAL THERAPY telehealth a covered service under my out-of-network benefits?  If so, what is the coverage?”
2. “What procedure (“CPT”) codes is the physical therapist able to bill for telehealth?”
3. “Are there any particular “modifier” codes that need to be used or specified by the physical therapist on the invoice?”
4. “Are there any requirements on my location during the visit?”
5. “Are there any additional requirements that I should be aware of?”

***Please keep in mind that Convergent Movement and Performance is able to provide services within all of these locations regardless of whether your insurance provider offers reimbursement. The purpose of discussing this with your insurance provider is to determine whether you may be reimbursed for these services.  It does not preclude you from receiving the services.   

“Do I have a deductible that must be met prior to receiving reimbursement for out-of-network physical therapy services?” (YES / NO)

• If no:
  • Continue to step 6
• If yes:
  • “What is the deductible?” ( $ __)
    • (Once you receive the deductible amount, continue to step 6)

FAQ: What is a deductible?

This is the total amount you must pay out-of-pocket before your insurance starts to pay.

For example, if your deductible is $1,000, then your insurance won’t pay anything until you have paid $1,000 for services subject to the deductible (keep in mind that the deductible may not apply to every service you pay for).

Furthermore, even after you’ve met your deductible, you may still owe a copay or co-insurance for each visit.

A deductible must be satisfied before the insurance company will pay for therapy treatment. Submit all bills to help reach the deductible amount.   

“What reimbursement will I receive when seeing an out-of-network physical therapy provider?”   

Additional information

• If you have a deductible (as determined in the previous step), you will not receive any reimbursement from your insurance company until you have reached the deductible.
• Most often, reimbursement for out-of-network services is provided based on a percentage of the overall cost per session. In other words, the insurance company will cover a set percentage (example: 70%) of each session.
• 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 you have an office visit co-pay the insurance company will subtract that amount from the percentage they will pay. This will affect the amount of reimbursement you will receive.

“Am I required to have a written prescription from a physician or other healthcare provider in order to be covered for out-of-network outpatient physical therapy services?”  (Yes/No)

• If Yes:
  • “Is there a requirement on which healthcare professional(s) can or cannot provide the prescription?” 
    • For example: primary care physician vs. orthopedist/neurologist/other specialist vs. podiatrist
• If No:
  • Continue to step 8

Additional information

If your policy requires a prescription or referral from another healthcare provider you must obtain one to send in with the claim. If the referral from an 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. 

“Am I required to receive pre-authorization, or have a referral on file, prior to beginning out-of-network physical therapy services?”  (Yes/ No)

• If Yes:
  • “How do I go about getting and submitting pre-authorization or a referral?” 
• If No:
  • Continue to step 9

Additional information

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 your physician’s office.

Ask them to file a referral for your physical therapy treatment that is dated to cover your first physical 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 your physician to submit a request for more treatment. 

“Is there a $ or visit limit in how much out-of-network physical therapy services I can be reimbursed for per year? (Yes / No)

• If yes:
  • What is the limit?
  • “Has any money or visits been applied to the limit for this year yet?  If so, how much?
• If no:
  • Continue to step 10

“I plan to independently submit my own claims on my own behalf for out-of-network physical therapy services…”

1. “What specific information and documentation is required to be submitted along with the claim?”
2. “Do you require a special form to be filled out to submit a claim? If so, where can I obtain the form?”
3. “How do I go about independently submitting my claims for out-of-network physical therapy benefits? Where and how should I submit the claims?”

“Is there any additional information I should be aware of in terms of submitting for, and receiving, reimbursement for out-of-network physical therapy services?” 

1. “If you don’t mind, can you please provide me with a reference number for this call?” 
2. “And I’m sorry, what is your name again?”
3. Record (write down) time of phone call