We are an out-of-network or non-participating provider. As a non-participating provider, physical therapy services are provided, and patients then pay the provider directly in full. Payment to the provider is anticipated on the same day the services are rendered. For most (not all) private insurance companies, we eliminate the step of claim submission by the patient. Instead, as a courtesy to our patients, we submit the claims electronically on behalf of the patient. The electronic claim submission is not a guarantee of benefits. Patients are responsible for reviewing the claim submissions through their insurance portals.
In advance of your appointment, we recommend calling your insurance company to be prepared for your out of pocket anticipated expense. Below is a guide to assist you with your inquiry when speaking to the insurance company.
Insurance procedures may vary, this is an example and should not be considered a guarantee of benefits or reimbursement.
- Call your health insurance member services number (typically located on the company website or the back of your insurance card) prior to your first date of service.
- Request “care coordination”, “care notification” or “notify of a procedure”.
- Please have the Graham Therapy and Fitness, P.A. information below to reference during your phone call to the insurance company:
|CPT Codes||97163||Physical Therapy Evaluation: High Complexity|
|97162||Physical Therapy Evaluation: Moderate Complexity|
|97161||Physical Therapy Evaluation: Low Complexity|
|97164||Physical Therapy Re-evaluation|
|Potential Visits||varies and based on hours||Estimate 32-40 hours for initial Schroth/scoliosis specific program|
|Quantity of CPT codes used per day||4-16 codes||1 code is equal to 8-15 minutes|
|Location where services were given||Ambulatory Outpatient Physical Therapy Home Clinic|
|Name of the facility where you provided services||Graham Therapy and Fitness, P.A.|
|On what basis were the services performed||Outpatient|
|Type of clinician providing services||Physical Therapist|
- They may ask how many times each code may be used (see above).
- Record the date of your phone call, obtain a case reference number and person you spoke to for future reference.
- When speaking with the insurance company be specific and explain in one day, there may be 16 physical therapy CPT codes billed.
- Understand your deductible amount. For example, you may have a $6000 deductible to meet before any out of pocket expenses will be reimbursed.
- It sometimes is helpful (though not required) to have a physician write a prescription which reads: Physical therapy Evaluation and Treatment for 1-2x/day for 2-4 hours per day for 32 hours spread out over 2-8 weeks, then follow up prn.
For those patients who do not have health insurance or those who have maxed out their benefits, we offer a private pay plan and offer financial planning, so that you may attend your sessions. Please contact Graham Therapy and Fitness today for more information on our fees for service and payment details.
Disclaimer: Health plans do change regularly without prior notification. We recommend that you verify with your health plan what physical therapy benefits you have available and also continue to monitor the insurance response throughout the course of your physical therapy care.