Lifting the Veil: Understanding Your P.T. Insurance Coverage

Having a solid understanding of your insurance policy is important before making any medical appointment. Here at Shine Integrative Physical Therapy, we provide a complementary benefits check for our patients prior to the first visit. To further assist you in deciphering your benefits for our skilled physical therapy services, we've compiled the following terms and concept definitions:  

Deductible
This is the amount you pay for your health care services before your health insurance is required to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met and pid your $1,000 deductible for covered health care services. The deductible may not apply to all services. You will be billed for any deductible owed to Shine within a few weeks of your appointment. 

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. You will be billed for the co-insurance within a few weeks of your appointment. 

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.

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 100% for 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.

Authorizations
United Healthcare, Blue Cross Blue Shield, Health Net, Care Oregon, Oregon Health Plan, Workers Compensation, and Motor Vehicle Accidents 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 but -since we are in-network with these insurers- we must work with what they allow. The Shine team will work diligently to appeal any denied authorization requests and will re-apply for more authorized visits if and when they are needed. 

Do I need a prescription?
The state of Oregon no longer requires patients to obtain a prescription for physical therapy services. However, the following insurance plans still require a prescription dated no more than 30 days from the first visit:

  • All Motor Vehicle Accidents (cannot be from a chiroprator)
  •  Medicare
  •  Worker’s Compensation
  •  Department of Labor
  • School District
  • Care Oregon

Shine's Billing Process
Claims are sent by your PT through Athena Health who submits them to your insurance company for reimbursement.
Athena Health sends a statement to you after your insurance has processed the claim. This statement will be on your Patient Portal for optional online payment. For payment made in person, we accept cash, check, MC, Visa and Discover.

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.