Out-of-Network Insurance Guide
How to Understand and Use Your Out-of-Network Benefits for Occupational Therapy Services
Below are some questions you can ask your insurance provider to understand your coverage and reimbursement options.
**Disclaimer: The information provided here is intended to help you ask informed questions about your out-of-network benefits. However, insurance policies vary widely, and coverage is ultimately determined by your individual plan. I recommend confirming all details directly with your insurance provider, as I cannot guarantee reimbursement or the accuracy of insurance company responses.
1. Do You Have Out-of-Network Benefits?
Do I have out-of-network benefits for occupational therapy?
Are there any exclusions for specific conditions or diagnoses?
2. What Reimbursement Can I Expect?
What percentage of the cost will be reimbursed for out-of-network services?
Do you cover both evaluations (CPT 97165, 97166, or 97167) and therapy sessions (e.g., CPT 97530, 97110, 97112)?
What is my deductible for out-of-network services, and how much of it has been met this year?
Is there an out-of-pocket maximum for out-of-network services?
3. Submitting a Claim
What documentation is required for reimbursement? (Will you accept a superbill?)
How do I submit a claim? (Mail, email, or online portal?)
What is the timeframe for submitting a claim?
4. Restrictions and Limitations
Are there limits on the number of OT sessions covered per year?
Do I need a referral from my child’s doctor?
Is prior authorization required?
5. Billing and Payments
Are reimbursements sent to me (the parent)?
Does the plan cover telehealth OT services?
6. Follow-Up
Who should I contact if I have questions about a denied claim?
*Please note this guide is for informational purposes only and may not cover all aspects of your plan.
Updated 07.11.2025