Understanding Your Insurance Coverage for Physical Therapy

Currently, we accept only Medicare Part B, workers’ comp, and auto insurance (PIP). We are in the process of obtaining TRICARE/TRIWEST credentialing. We have included instructions for using your out-of-network benefits, as well as Medicare, auto (PIP), and workers’ comp, below to help you understand your insurance coverage and the necessary steps. As an alternative, we offer self-pay services that streamline the billing process for both parties by eliminating a third party (e.g., insurance). We will be happy to discuss rates over the phone or in person during your first visit.

This page is for general educational purposes and does not constitute legal advice.

Insurance coverage varies by policy; contact your insurer or attorney for case-specific guidance.

Confused by insurance? Most PPO plans reimburse out-of-network services to some extent. Use our Phone Script & Checklist below to find out exactly what your plan covers in under 5 minutes.

Using Your Out-of-Network Benefits

• Step 1: Check Your Benefits – Call your insurance provider and ask about "out-of-network physical therapy" coverage. Many PPO plans reimburse 50–80% of the cost once your deductible is met.

• Step 2: Get Your "Superbill" – We provide a detailed, itemized receipt (a Superbill) that contains all the necessary diagnostic and treatment codes. This can be done session to session, or any other timeframe you choose.

• Step 3: Submit & Get Paid – You upload that Superbill to your insurance portal or mail it in. They send the reimbursement check directly to you.

• Step 4: Use Your HSA/FSA – Remember, you can use Health Savings Account or Flexible Spending Account funds to pay for all sessions at TVPT, making your care tax-free!

Patient Checklist: Calling Your Insurance

Before you call, have your insurance card and a pen ready. Call the member services number on the back of your card and ask to speak with a representative about your out-of-network outpatient physical therapy benefits.

The Essential Questions:

• Do I have out-of-network benefits?

  • If not, you can still see us, but your plan won't cover the cost. We offer payment plans and package deals since your care comes first.

• What is my out-of-network deductible?

  • This is separate from your in-network deductible. Ask: "How much of it have I already met this year?"

• What is my "reimbursement rate" or "coinsurance"?

  • Common rates are 60%, 80%, or 90% of the "allowable amount."

• Is there a limit on the number of visits per year?

  • Some plans cap visits at 20 or 30 per calendar year.

• Do I need a physician’s referral or "pre-authorization" for out-of-network care?

  • Even though Oregon is a direct access state, some insurance plans still require a referral and/or authorization to process a claim.

• How do I submit a "Superbill"?

  • Inquire whether there is an online portal or a designated mailing address for member-submitted claims.

Pro-Tip: Ask the representative for a reference number for the call. This is helpful if there is ever a dispute about the information they provided to you.

The "Out-of-Network" Call Script

The Intro:

"Hi, I’m calling to verify my outpatient physical therapy benefits. I am planning to see an out-of-network provider. Can you tell me what my coverage looks like for this?"

The Specifics:

"I specifically need to know my out-of-network deductible and what percentage of the 'allowable amount' you cover once that deductible is met. Also, is a physician’s referral or prior authorization required for me to be reimbursed?"

The Closing:

"Thank you. Could I please get a reference number for this call and the name of the representative I’m speaking with?"

Medicare Part B Insurance Coverage

What patients should know:

Medicare Part B typically covers outpatient physical therapy services when they are considered medically necessary to treat an illness, injury, or condition. This includes recovery after surgery, injury rehabilitation, or treatment of chronic pain, provided the care meets Medicare's standards for medical necessity.

Medicare does not allow cash payment for services that could be covered under Part B. Even if prescribed by a physician, we cannot accept out-of-pocket payments from Medicare beneficiaries for treatments covered under Medicare.

However, there are limited exceptions:

• Patients may self-pay for services that are clearly non-covered, such as general wellness or fitness programs (not traditional PT).

• Patients may also pay for therapy services exceeding the annual threshold (currently $2,480 in 2026) if those services are documented as medically necessary and billed according to Medicare’s fee schedule.

What we do to help:

• We verify your Medicare coverage and ensure services meet Medicare’s documentation and billing standards.

• We coordinate with your referring provider if needed.

• We help you understand any coinsurance responsibilities (typically 20%) and whether you have secondary insurance like Medigap to cover those costs.

  • We are out-of-network with Medicare Advantage (Part C)

• We follow strict Medicare rules to protect your benefits and to maintain full legal compliance.

If you're unsure whether your situation qualifies, we're happy to discuss your options. You can call us at (971) 238-5755