About Out-Of-Network Benefits

Clients insured by Medicare, Medicare Advantage Plans, or Medicaid/Mainecare are not eligible to pay cash, or seek reimbursement, for routinely covered physical therapy care.

Working with an Out-of-Network, cash based, physical therapist means that services are paid for up front by you, the client. However, some commercial insurance plans do include specific Out-of-Network benefits. Terms and conditions can vary widely, and reimbursement is not guaranteed.

If you plan to submit for reimbursement, it is important to communicate with your insurer in advance to improve the likelihood of a successful reimbursement request. Reimbursement is not guaranteed.

Verifying Your Out-of-Network (OON) Benefits

1. Before scheduling your first appointment, call the member services number on the back of your insurance card to ask these questions:

  • "Does my plan have out-of-network benefits, and do they require prior authorization for outpatient physical therapy?"

    • If prior authorization is required, ask where forms can be found online or to have copies emailed or mailed to you.

  • “How do I submit any necessary documentation for a prior authorization?”

  • "What is my out-of-network deductible and coinsurance percentage?"

  • “Maine is a direct access state for physical therapy. Does my plan recognize that or still require a specific referral from my medical provider?”

  • “Are there any restrictions or requirements specific to telehealth physical therapy?”

‍*If there are no in-network pelvic health physical therapists within a reasonable distance from your home, or offering telehealth:

  • "If authorized, will these services be processed at an in-network level due to network gaps?"

  • “How do I submit claims for reimbursement after I have seen my physical therapist?”

2. Gather Clinical Documentation

Decades Physical Therapy will assist in providing any necessary paperwork to justify the medical necessity of your care, including:

  • Documentation of your treatment and/or medical diagnosis

  • A copy of the first visit’s Evaluation & Plan of Care

  • Anticipated billing codes (e.g., 97110 for therapeutic exercise)

  • The expected frequency and duration of treatment.

  • A copy of a “Superbill” for each completed visit

NOTE: Printed and digital medical records requests may be subject to an additional fee.

3. Submitting the Request & Following Up

  • Once you have the required documents, follow these steps to secure approval:

  • Submit the paperwork: Send the clinical documents directly to your insurer’s medical management or pre-certification department.

  • Get a reference number: Always ask for a reference number or tracking number for your phone call or submission.

  • Confirm turnaround time: Insurers typically make a decision in 10 to 14 days.

  • If your treatment is urgent, specifically request an expedited review.

4. Document everything:

Be sure to note the name of the representative you spoke with, the date, and the outcome.