How to Use Your Out of Network Benefits for Pelvic Floor Physical Therapy and Get Reimbursed
When you are looking for pelvic floor physical therapy, you may notice that some of the clinics offering specialized pelvic health care are private pay or out of network with insurance.
Choosing a private pay or out of network pelvic floor physical therapy clinic can come with benefits that are important to consider when deciding where to receive care.
Why Choose a Private Pay Pelvic Floor Physical Therapy Clinic?
Private pay clinics often have more flexibility in how they structure care. Depending on the clinic, this may allow for longer appointments, more individualized attention, specialized treatment approaches, and a care plan that is tailored to your specific goals rather than being limited by insurance coverage or visit restrictions.
For pelvic floor physical therapy in particular, individualized care can be especially valuable. Pelvic health concerns can be complex and may involve multiple factors, including movement, breathing, strength, coordination, lifestyle, and whole body function. Having the time and space to look at the bigger picture can make a meaningful difference in your care experience.
Choosing an out of network provider can also give you access to a pelvic floor physical therapist who specializes in your specific needs, even if that provider is not part of your insurance network.
But there is an important question that often comes up:
If I choose a private pay or out of network pelvic floor physical therapist, do I have to pay the entire cost myself?
Not necessarily.
Many health insurance plans include out of network benefits, which may allow you to receive reimbursement for a portion of your pelvic floor physical therapy costs after you pay for your care upfront.
The process typically involves confirming your out of network benefits, paying your provider directly, receiving a document called a superbill, and submitting a claim to your insurance company for potential reimbursement.
In this guide, we will walk you through how out of network pelvic floor physical therapy reimbursement works, what questions to ask your insurance company, what a superbill is, how to submit a claim, and what to do if your claim is denied.
Step 1: Check Your Out of Network Physical Therapy Benefits
Before your first appointment, call the member services number on the back of your insurance card.
This is one of the most important steps because your coverage can vary significantly from one insurance plan to another.
Ask the representative to explain your out of network physical therapy benefits and write down the answers. It can also be helpful to ask for the representative's name and a reference number for the call.
Questions to Ask Your Insurance Company
Here are some questions to have ready:
Do I have out of network benefits for physical therapy?
What is my out of network deductible?
How much of my out of network deductible have I already met this year?
What is my coinsurance after I meet my deductible?
Is there an annual visit limit for physical therapy?
Do I need a referral for out of network physical therapy?
Do I need prior authorization?
Is pelvic floor physical therapy covered under my plan?
How do I submit an out of network claim?
Is there a specific claim form I need to complete?
Can I submit my claim through an online portal or mobile app?
What is the filing deadline for submitting claims?
Your insurance company may have a separate out of network deductible that is different from your in network deductible. Once the deductible is met, your plan may cover a percentage of the allowed amount for eligible services.
Understanding these details before starting treatment can help you better estimate your potential out of pocket costs.
Step 2: Ask Your Pelvic Floor Physical Therapist for a Superbill
If your pelvic floor physical therapist is out of network with your insurance, you may need a superbill to submit for reimbursement.
A superbill is an itemized document that provides your insurance company with the information needed to process your out of network claim.
Think of it as a detailed medical receipt.
A regular payment receipt generally shows that you paid for a service. A superbill contains additional clinical and billing information that your insurance company may require to process your claim.
At Weeks Wellness, patients can request superbills for their physical therapy visits.
What Information Is Included on a Superbill?
A complete superbill may include:
Provider information: Your physical therapist's name, credentials, and National Provider Identifier (NPI)
Clinic information: The clinic's name, address, and Tax ID
Patient information: Your name, date of birth, and insurance member information
Dates of service: The date each physical therapy session occurred
Diagnosis codes: ICD 10 codes associated with your condition or reason for treatment
Procedure codes: CPT codes that describe the services provided
Amount charged: The amount you paid or were charged for the services
Before submitting your superbill, review it carefully to make sure the information is complete and accurate.
Step 3: Submit Your Out of Network Insurance Claim
Once you have your superbill, you can submit your claim to your insurance company.
The exact process varies by insurance provider, but most claims follow a similar process.
1. Find Your Insurance Company's Claim Form
Visit your insurance company's website or call member services to find out how to submit an out of network physical therapy claim.
Some insurance companies allow you to submit claims electronically through an online member portal or mobile app. Others may require a paper claim form.
2. Complete the Claim Form
Fill out the required information and attach your superbill.
Make sure your information matches what is listed on your insurance policy and that all required fields are completed.
3. Submit Your Claim
Submit your claim using the method provided by your insurance company.
If you are mailing your claim, keep a copy of everything you send for your records.
If you submit electronically, save your confirmation or submission receipt.
4. Follow Up on Your Claim
Insurance processing times vary.
If you have not received an update within the timeframe provided by your insurance company, contact member services and ask about the status of your claim.
Have your claim information and any submission confirmation available when you call.
5. Review Your Explanation of Benefits
After your insurance company processes your claim, you should receive an Explanation of Benefits (EOB).
Your EOB can show:
The amount submitted to insurance
The amount your insurance company considers allowable
How much was applied toward your deductible
The amount covered by your plan
Your remaining responsibility
Review your EOB carefully. If the information does not match what you expected based on your benefits, contact your insurance company for clarification.
What If Your Out of Network Physical Therapy Claim Is Denied?
Receiving a denial does not necessarily mean the process is over.
First, look at your EOB or denial notice to understand why the claim was denied. Your insurance company should provide information about the reason for the denial and, in many cases, instructions for appealing the decision.
Common Reasons an Out of Network Claim May Be Denied
Missing or incorrect information
Your claim may be missing information or contain an error. Review the superbill and claim form for items such as the provider's NPI, Tax ID, diagnosis codes, procedure codes, dates of service, and patient information.
Referral or prior authorization requirements
Some insurance plans require a referral or prior authorization for certain physical therapy services. Confirm your plan's requirements before beginning treatment whenever possible.
Medical necessity questions
An insurance company may determine that a service does not meet its coverage criteria for medical necessity. If this occurs, review the denial instructions and ask your healthcare provider what documentation may be appropriate for an appeal.
No out of network benefits
Some insurance plans do not include out of network coverage for physical therapy. If your plan does not provide this benefit, ask your insurance company about other options available under your specific plan.
How to Appeal an Out of Network Physical Therapy Denial
If your claim is denied and you believe the service should be covered, you may have the option to appeal.
Start by requesting the denial reason and appeal instructions from your insurance company.
Depending on the reason for the denial, your provider may be able to help you gather supporting documentation, which could include clinical records or a letter of medical necessity when appropriate.
Make sure you follow your insurance company's appeal instructions and submit everything by the required deadline.
Can You Use an HSA or FSA for Pelvic Floor Physical Therapy?
If you have an HSA or FSA, you may be able to use those funds for eligible healthcare expenses, including qualifying physical therapy services.
Eligibility and documentation requirements can vary, so check with your HSA or FSA administrator regarding your specific account.
Even if your insurance does not reimburse the full cost of your pelvic floor physical therapy, an HSA or FSA may provide another way to use pre tax healthcare funds for eligible expenses.
Your Out of Network Pelvic Floor Physical Therapy Checklist
Before you begin treatment, use this checklist to stay organized:
Call your insurance company and confirm your out of network physical therapy benefits
Ask about your out of network deductible and coinsurance
Confirm whether you need a referral or prior authorization
Ask how to submit an out of network claim
Save the name and reference number from your insurance calls
Request a superbill from your physical therapist
Review your superbill for accuracy
Get your insurance company's claim form if one is required
Submit your claim before your plan's filing deadline
Keep copies of everything you submit
Review your Explanation of Benefits when your claim is processed
If your claim is denied, review the denial reason and appeal instructions
Frequently Asked Questions About Out of Network Pelvic Floor Physical Therapy
What is a superbill for pelvic floor physical therapy?
A superbill is an itemized document from your physical therapy provider that includes billing and clinical information your insurance company may need to process an out of network reimbursement claim. It can include the provider's NPI, clinic Tax ID, diagnosis codes, procedure codes, dates of service, and amount charged.
How much will insurance reimburse for out of network pelvic floor physical therapy?
The amount depends on your individual insurance plan. Your reimbursement may depend on factors such as your out of network deductible, coinsurance, allowable amount, visit limits, and the specific services covered by your plan.
The best way to determine your potential reimbursement is to contact your insurance company before beginning treatment and ask specifically about your out of network physical therapy benefits.
What CPT codes are used for pelvic floor physical therapy?
Pelvic floor physical therapists may use different CPT codes depending on the services provided during your appointment. Common physical therapy codes can include codes for therapeutic exercise, manual therapy, therapeutic activities, and neuromuscular re education.
The specific codes used should reflect the services provided during your visit, and your provider's superbill will list the applicable codes.
Can I use my HSA or FSA for pelvic floor physical therapy?
You may be able to use HSA or FSA funds for eligible physical therapy expenses. Check with your plan administrator to confirm eligibility and any documentation requirements.
How long does out of network physical therapy reimbursement take?
Processing times vary by insurance company and claim. If your claim has been pending longer than the timeframe provided by your insurer, contact member services and ask for an update.
What should I do if my out of network pelvic floor physical therapy claim is denied?
Start by reviewing your Explanation of Benefits or denial notice to determine why the claim was denied.
If your plan allows an appeal, follow the instructions provided by your insurance company and submit the requested documentation before the deadline. Your physical therapist may also be able to help provide appropriate clinical documentation when needed.
Pelvic Floor Physical Therapy Should Be About Getting the Care You Need
Finding the right pelvic floor physical therapist is an important part of getting care that fits your specific needs.
Being out of network does not automatically mean you cannot use your insurance benefits. If your plan includes out of network coverage, submitting a claim with a superbill may allow you to receive reimbursement for eligible services.
The most important first step is to call your insurance company and understand your benefits before beginning treatment.
At Weeks Wellness, our pelvic floor physical therapy teams work with patients to make the process of accessing specialized pelvic health care as straightforward as possible.
Whether you are looking for pelvic floor physical therapy for pelvic pain, urinary symptoms, postpartum recovery, bowel dysfunction, painful intercourse, diastasis recti, or another pelvic health concern, our team is here to help you understand your care options.
Ready to get started? Find your nearest Weeks Wellness location or contact our team and we can walk you through the reimbursement process.
