Out-of-network physical therapy reimbursement means you pay the therapist yourself, then send your insurer an itemized bill (often called a superbill) and ask it to pay you back under your out-of-network benefit. PPO and POS plans often have that benefit, usually with a separate deductible and higher coinsurance; HMO and EPO plans generally do not cover out-of-network care at all. Whether a given therapist provides a superbill is a question for that therapist’s office.
Last reviewed By the Monon Therapy Collective editorial team
- Plans that usually reimburse
- PPO and POS plans with out-of-network benefits
- Plans that usually do not
- HMO and EPO, except emergencies
- What you send
- An itemized bill with codes, plus a claim form
- Your share
- Out-of-network deductible and coinsurance, plus any balance
Which insurance plans pay anything back for an out-of-network therapist?
Plans with an out-of-network benefit, which in practice means most PPOs and POS plans. HealthCare.gov describes PPOs as letting you use providers outside the network for an additional cost, while HMOs generally will not cover out-of-network care except in an emergency and EPOs cover services only from network providers.
Look in your Summary of Benefits and Coverage for a separate out-of-network column. If it says “not covered”, a superbill will not change that. If it shows a deductible and a percentage, you have a benefit to claim against. Medicare Advantage PPOs follow similar logic, covered on the Medicare Advantage page.
How much will your insurer actually reimburse?
Your plan pays a percentage of its allowed amount, not of what the therapist charged. HealthCare.gov defines the allowed amount as the maximum the plan will pay for a covered service, and out-of-network coinsurance as the percentage of that allowed amount you pay, using 40% as its example.
So two gaps can appear. First, you pay the out-of-network deductible before any reimbursement starts. Second, if the therapist’s charge is higher than the allowed amount, the difference is yours; this is balance billing, and an out-of-network provider has no contract with your plan that prevents it. The in-network versus cash-based comparison shows how these numbers stack up.
| Piece of the bill | Who pays it |
|---|---|
| Out-of-network deductible | You, until it is met for the year |
| Coinsurance on the allowed amount | Shared: the plan pays its percentage, you pay the rest |
| Charge above the allowed amount | You (balance billing) |
| Services your plan excludes | You, in full |
What should a physical therapy superbill include?
A superbill is an itemized statement detailed enough for an insurer to process. It needs to identify the provider, the patient, the diagnosis and the services in the coded form insurers use, along with dates and amounts paid.
Not every practice issues one, and the network cannot promise any therapist does. Ask the therapist’s office before your first visit whether it provides superbills and how often. Insurers can also ask for the plan of care or visit notes to judge medical necessity, so keep those available. Mention in the physical therapy questionnaire that you plan to claim out of network, and the matching team will raise the superbill question with the therapist it proposes.
- Practice name, address, NPI number and tax ID
- The therapist’s name and license credential
- Your name, date of birth and member ID
- Diagnosis codes (ICD-10)
- Procedure codes (CPT) and units for each date of service
- Charge for each service and the amount you paid
Do federal surprise-billing rules protect a planned out-of-network therapy visit?
Generally not. The No Surprises Act protections that CMS describes focus on emergency care, out-of-network providers working at in-network facilities, and air ambulances. Choosing an independent out-of-network therapist for planned outpatient care is a different situation, so balance billing rules from your plan apply.
What you do have, if you are not using insurance for the visit, is the right to a good faith estimate of charges. Many people paying up front and claiming later treat themselves as self-pay at the office; the self-pay page covers that estimate.
How do you file an out-of-network physical therapy claim?
The exact form and address are on your insurer’s member website. These are the usual steps.
Check your out-of-network benefit
Confirm your plan has an out-of-network column for outpatient rehabilitation, and note the deductible, coinsurance and any visit limit or approval rule.
Ask the therapist’s office about paperwork
Before the first visit, ask whether the practice provides an itemized superbill with diagnosis and procedure codes, and how often.
Pay and collect the itemized bill
Pay the practice directly and keep the superbill and payment receipt for every date of service.
Complete the insurer’s claim form
Download the member claim form, fill it in, attach the superbill and send it by the method your insurer lists, keeping copies.
Track the explanation of benefits
Compare the explanation of benefits with your plan’s rules, and appeal in writing if a covered claim is denied or underpaid.
