Understanding P.T. Insurance Terminology

Please remember that Shine is an out-of-network provider for all insurances, including Medicare. Please also read our Payment Information page and call your insurance provider before your first visit with us.

Health Savings and Flexible Spending Accounts
These are common ways to pay for out-of-network or pre-deductible charges for your health care. Shine PT accepts both HSA and FSA card payments.

Deductible
This is the amount you pay for your health care services before your health insurance is required to pay. It is generally lower for in-network clinics and providers. For example, if your deductible is $1,000, your plan will not reimburse you until you’ve met and paid your $1,000 deductible for covered health care services. Submitting your receipt (SuperBill) to your insurance will allow them to credit these payments towards your deductible. The deductible may not apply to all services.

Co-insurance
This is your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay the co-insurance plus any deductibles you owe after the insurance has paid its portion. For example, if the plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. In this example, your health insurance pays the remaining $80 which is what you would be reimbursed from your insurance.

Co-pay
This is a fixed amount (for example, $15) you pay for a covered health care service, when you get the service. The amount can vary by the type of covered health care service. You are required to pay your co-pay at the time of your appointment so this amount will not be refunded to you if your insurance reimburses your visit.

Out-of-pocket max
This it the highest amount you are required to pay during a policy period (usually one year) before your health insurance or plan starts to pay or reimburse covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual, which is a qualified medical expense for the essential health benefits.

Prior Authorizations
United Healthcare, Blue Cross Blue Shield, Health Net and Moda plans often require prior authorization for physical therapy services. During your initial visit, you and your physical therapist will create a plan of care. The team at Shine will fill out the required authorization forms based on that plan of care and will then submit this information to your insurance company. The number of visits authorized may be lower than what your PT prescribed. The Shine team will re-apply for more authorized visits if and when they are needed for a small fee.

Are referrals and prescriptions required?
The state of Oregon no longer requires patients to obtain a prescription for physical therapy services.

In closing
We hope this brief summary assisted you in understanding the basics of your insurance coverage for skilled physical therapy services at Shine. We are happy to help with your individual questions if you are in need of more specific assistance. Please call or email us at your convenience so there are no hurdles to you receiving the care you need.