Out-of-Network Insurance Guide

How to Understand and Use Your Out-of-Network Benefits for Occupational Therapy

If you're using out-of-network benefits to access occupational therapy services, we want to make the process as easy as possible. 

Below are key 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 12.05.2024