Insurance Terms

Co-pay
A fixed amount your insurance company charges for specific medical services per visit and are payable at the time of service.

Example: $20 due at each physical therapy visit.

Co-insurance:
A percentage of costs your insurance company requires you to pay after your deductible has been met. These are billed to you once your insurance company processes a claim and determines your patient responsibility. Payment is due upon receipt. 

Example: 20% of costs of each visit.

Deductible:
The portion of medical costs not covered by your insurance company. It is the amount you are required to pay before your health plan begins making payments on your claims. Usually, but not always, per calendar year. Ask for details from your insurance company.

Example: $500 towards covered costs before your insurance pays any physical therapy claims

Out-of-pocket maximum:
The maximum amount you are required to pay for covered expenses in a calendar year.

Example: $1000 paid by you towards all costs including physical therapy, surgery and diagnostics.

Prescription:
A prescription is a physician order for physical therapy. It generally includes the patient’s name, a diagnosis, a treatment plan (or evaluate and treat), the physician’s name and the date. This may be from your primary care physician, an orthopedic specialist, a neurologist, nurse practitioner or physician assistant, etc. This is the medical piece related to your diagnosis.

Referral:
A process initiated by your primary care physician so you may see a specialist, such as a physical therapist. This is not the same as a prescription. If your insurance requires a referral, your PCP is the one who enters this information which allows us to bill your insurance for these first set of visits. You must contact your PCP so they can process your referral request. This is an insurance/ billing issue related to your benefit requirements. Once you use these visits, your PT will then submit paperwork to your insurance company updating your medical status and requesting additional visits based on medical necessity.

Authorization:
A certification or authorization that an insurance company approves prior to a physical therapy visit. This generally includes a specific number of visits and provides a time frame for those to occur. Your therapist may request additional visits from your insurance company provided it is medically necessary. It does not guarantee payment beyond benefit limits.

Insurance plans differ greatly in their requirements. One or more of these requirements may apply to your plan . We suggest you contact your insurance company to determine what is needed and what applies to your coverage.