Insurance
Basics
Basics
Some insurance plans require this before they will cover physical therapy services, confirming that the treatment is necessary for your health.
What is Prior Authorization?
This part of Medicare covers outpatient care and preventive services.
What is Part B?
This is a document from a doctor, often required by insurance, allowing you to begin physical therapy.
What is an order/referral/prescription?
You run HDX and the policy shows as terminated, but the patient insists it’s active. What are your next steps?
Task the verification team to confirm policy information and benefits.
What should PSCs be using to verify insurance payers and plans before allocating anything in Soarian?
Soarian Payer Guide
What is the PREFFERED identification number for allocating true Self Pay policies?
What is SSN?
What does a patient generally buy to cover the 20% coinsurance after the Medicare deductible is met?
What is a supplement or secondary insurance?
The initial amount you pay out-of-pocket for healthcare services before insurance kicks in
What is the deductible?
You notice the patient’s plan lists 20 combined visits for PT/OT/ST but they already have 18 PT visits logged. What’s the risk here?
Insurance stops paying for services after the patient is seen 2 more times and the patient receives an unexpected bill.
What type of plan is considered the "Rule of Lasts" as far as allocation is concerned?
What is Medicaid Plans?
What is the difference between a Group Health Plan (GHP) and a Marketplace Plan (MP?)
GHPs are offered through employers and MP plans can be bought from anyone.
This type of Medicare plan may include additional benefits like vision or dental.
What is Part C or Medicare Advantage?
When a patient's insurance does NOT require a referral to be seen for physical therapy services
You notice a MCD patient has a commercial plan under the additional coverage tab but they ask you not to allocate it. What would you tell the patient?
If the proper insurances aren't allocated correctly, then Medicaid may refuse to pay for the entire service, leaving the patient with a bill.
If a child has 2 active commercial insurances by both of their parents, what rule do we use and explain it.
What is the Birthday Rule? Whichever parent's BIRTH MONTH falls first, regardless of actual age, that parent's plan will act as primary.
What is Auto Insurance and Worker's Comp Claims?
What is the standard Part B Medicare deductible for patients as of 2025?
What is $257?
What does COB stand for and what does it mean?
What is Coordination of Benefits? COB is the guidelines for how insurance plans are allocated.
There is a same day eval and the verif hasn't come back yet. The financial responsibility form needs filled out. What resource can you use to complete it?
The HDX 'View Response" box. The tabs at the top will let you click through the most updated information for deductibles, copays, OOPs, etc.
What do we utilize to determine the allocation rules for active GHPs in addition to MCR based on age or disability?
MSPQ in Soarian
This document is sent by the insurer explaining what is covered for a medical service.
What is Explanation of Benefits (EOB)?
As of 2025, what is the combined threshold for PT/SPL and OT services for Medicare patients each year?
What is $2,410?
!!!DAILY DOUBLE!!!
What are ICD and CPT codes?
A patient's Facesheet has an active MCR A and B plan allocated followed by an active Humana MCR Adv plan. What's the red flag here and why?
Both plans should not be allocated at the same time. MCR A and B will always show active but the advantage was bought to REPLACE the A and B plan.
What does HDX stand for?
What is Healthcare Data Exchange?