Understanding Your Insurance Plan Benefits

by | May 10, 2019 | Physical Therapy

As the billing manager for TEAM 4 Kids Pediatric Therapy Centers I get many questions throughout the day about various insurance plans. Health insurance can be overwhelming and confusing for many families. I have put together 9 key questions to ask your insurance provider to ensure you have all of the information you need to understand your insurance benefits. Not all providers are contracted with all insurance plans, it is imperative to provide all insurances your child is covered under to maximize policy benefits and minimize the cost of care. When contacting your insurance provider(s) prior to services rendered, it’s important to understand what is covered AND what the exclusions are to your policy with regard to therapy services.

9 Key Questions To Ask:

  • Does this policy cover services for my child’s diagnosis for the following therapy related CPT codes?
  • Does this policy require authorization for evaluations and/or ongoing therapy?
  • Is there a maximum number of visits per therapy type, per calendar year or plan year?
  • Do I have a deductible driven plan or copay driven plan?
  • When does my deductible reset?
  • How much is my deductible OR How much is my co-pay?
  • Have I hit my deductible? If not, how much is remaining until I do?
  • What is my co-insurance after I hit my deductible?
  • What is covered after meeting my out of pocket maximum?

Key Points:

  • If your insurance policy terminates, it is imperative to notify providers immediately as any services rendered without insurance coverage becomes an out of pocket expense to the family.
  • When a policy is added, or is terminated, be sure to contact both your provider and the active insurance policy to complete a Coordination of Benefits. This process notifies the insurance carrier(s) of who is responsible as primary/secondary payor for payment when a claim is billed.
  • AHCCCS insurance plans go through a re-enrollment process, it is important to keep an eye out for notifications about renewing your policy and/or plan changes. A lapse in coverage can result in an out of pocket expense.

The key to maximizing therapy sessions and cost of care is understanding the benefits your healthcare plan provides. To contact your insurance provider please see the phone number for member services listed on your insurance card.

Shasta Torba, Billing Manager