North County Water & Sports Therapy Center April 2019

Coinsurance A type of patient financial responsibility in the amount of a percentage of allowed charges. For example, an 80/20 plan indicates the insurance will pay 80 percent of the allowed amount (once the deductible has been reached), and the patient is responsible for 20 percent of the allowed amount up until the out-of-pocket maximum has been met. Out-of-Pocket Maximum The maximum amount of money the patient has to pay themselves. There are yearly and lifetime out- of-pocket maximum amounts, depending on the patient’s medical insurance policy. Once the out- of-pocket maximum has been met, the insurance company pays at 100 percent (unless a maximum limit of the policy has been reached). Copay A specified amount of money the patient must pay at each visit. Copay amounts vary depending on the type of provider the patient is seeing. Policy Holder The person that holds the insurance contract or policy. For example, most children under the age of 18 have insurance under a parent or legal guardian as the policy holder. Primary Insurance Main insurance plan supplied by an employer or government. Secondary Insurance Supplemental plan that helps cover the costs not covered by the primary plan.

In-Network Provider Providers or health care facilities that are part of a health plan’s network of providers. Out-Network Provider Providers or health care facilities that are not part of a health plan’s network of providers. This often means the patient will have a larger share of cost. Direct Access The patient can seek safe, quality physical therapy services without the delay of first having to go to their physician for a referral. Under direct access in California, the consumer is allowed 12 visits to a physical therapist to be completed within a 45-day period, after which they need to see a physician should additional treatment be needed. Be advised that not all insurance companies will cover direct access and a prescription from your physician may still be required to cover the cost. We will call your insurance company for you to find out if a prescription is required and notify you prior to your appointment. Referral A written order from the patient’s primary care physician that will need to be obtained before receiving any medical services except by the primary care doctor. Referrals usually apply to HMO insurances. Note that the terms referral , script , and prescription are often used interchangeably and add to the confusion. Prescription A written order from the patient’s physician that must include the diagnosis, frequency and duration, goals of therapy, and safety precautions.

Do you need physical therapy? Not sure about your insurance coverage for physical therapy services? Call our front office at 858-675-1133 and we will be happy to help.

When you call, please have the following information ready to provide our front office:

• Name and date of birth of the person to be the patient • Name and date of birth of the policy holder • Insurance company name and phone number (provider/customer service number) • Insurance policy/member ID number and group number when applicable • Doctor name and phone number (if being sent by your physician)

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