Part 3: How Do I Actually Use My Out-of-Network Benefits? A Step-by-Step Superbill Guide (Kirkland PT)
This is Part 3 of a three-part series on paying for pelvic floor physical therapy. Part 1 covered why I'm a cash pay practice and how superbills work. Part 2 ran the real numbers on what a course of care costs before and after reimbursement.
Parts 1 and 2 explained the concept. This one is the how-to. By the end you'll know exactly what to say when you call your insurance company, what to do with the superbill I hand you, and roughly when to expect money back.
Step 1: Make the call
Find the member services number on the back of your insurance card. Not the provider line, the member line.
Your script: "Hi, I'd like to check my out-of-network benefits for outpatient physical therapy. Can you help me with that?"
Then work through these six questions. Write the answers down as you go.
1. Do I have out-of-network benefits for outpatient physical therapy?
If the answer is no, stop here. You can still use HSA or FSA funds, but there won't be reimbursement to chase. Most PPO plans say yes. Most HMO and EPO plans say no.
2. What is my out-of-network deductible, and how much have I met this year?
Ask specifically for the out-of-network number. Most plans keep a separate, higher deductible for out-of-network care.
3. What percentage do you reimburse for out-of-network physical therapy after my deductible is met?
Usually somewhere between 50 and 80 percent.
4. Is that percentage based on my provider's actual charge, or on an allowed amount?
This is the question almost nobody asks, and it's the one that explains a disappointing check later. Insurers often reimburse a percentage of their determination of a fair fee, not what you actually paid. If they use an allowed amount, ask what it is for CPT codes 97161 (evaluation), 97110 (therapeutic exercise), 97112 (neuromuscular re-education), and 97140 (manual therapy). Naming what the codes mean helps, since the person on the phone doesn't always know them by number either.
5. Do I need a physician referral or prior authorization for reimbursement?
Washington is a direct access state, so you don't need a referral to see me. But some plans still want one on file to reimburse you. Worth knowing before you've paid for six visits.
6. How do I submit a superbill, and what's the deadline for claims?
Ask whether they take uploads through the member portal, email, or mail only. Then ask for the timely filing limit, usually somewhere between 90 days and one year from the date of service.
Step 2: Come to your visit
Your superbill will already include everything an insurer needs: my NPI and Tax ID, the diagnosis codes, the CPT codes for what we did, the date of service, and what you paid.
Step 3: Submit the claim
Most plans now accept uploads through the member portal, which is the fastest route. Log in, find the claims section, and look for something along the lines of "submit a claim" or "out-of-network claim."
You'll usually need two things:
The superbill I gave you
The plan's member claim form, downloadable from the same section of the portal
The claim form is short. It asks for your member ID, the patient's information, and the provider's details, all of which are on the superbill. Where it asks for diagnosis and procedure codes, copy them straight across.
If your plan doesn't do portal uploads, ask member services whether they accept claims by email, or mail the packet to the claims address on your insurance card. If you mail it, keep a copy of everything.
Submit as you go rather than saving up a stack. It keeps you comfortably inside the filing deadline, and it starts the clock sooner.
Step 4: Watch for the EOB
A few weeks after you submit, you'll get an Explanation of Benefits. It is not a bill. It's a summary of what the insurer decided: what they allowed, what they applied to your deductible, and what they're reimbursing.
Read it against your own notes from Step 1. If the reimbursement percentage doesn't match what you were told, that's worth a phone call.
Most out-of-network claims process in two to six weeks. If you haven't seen an EOB after 30 days, call member services and ask for a status update using the claim number.
What reimbursement actually feels like
Think of it as a rebate in the mail, not a discount at checkout. You pay the full amount at your visit, and money comes back later. That timing matters for budgeting, especially early in a plan year when you may be filling your deductible rather than getting checks.
Part 2 walks through the math on a full course of care if you want to estimate your own numbers.
Common questions
What if my deductible isn't met yet? Submit anyway. Every claim you file counts toward your out-of-network deductible, which means you're moving toward the point where reimbursement kicks in. Skipping submissions just delays that.
Can I use my HSA or FSA and still submit a superbill? Usually yes, with one caution: don't double-dip. If insurance reimburses a visit you already paid for with HSA funds, you can't simply pocket that check. The money generally needs to either go back into the account or go toward other qualified medical expenses, since it was never taxed on the way in. Keep clean records, and ask your plan administrator how they want it handled. I'm a physical therapist rather than a tax advisor, so this is one worth confirming with them.
Is reimbursement guaranteed? No. It depends on your plan having out-of-network benefits and on their rules for referrals and documentation. That's exactly why the call in Step 1 matters. What I can promise is a complete superbill for every visit and a clear price before you book.
What if I have Medicare? Federal rules prevent me from providing physical therapy treatment to Medicare beneficiaries, even if you'd prefer to pay out of pocket. I can offer wellness services such as fitness and general conditioning work that falls outside the scope of PT treatment.
And that’s a wrap
Part 1 covered why I built the practice this way. Part 2 ran the numbers. This one handed you the script.
If you'd rather just talk it through with a person, reach out through my inquiry page. I'm happy to walk you through your specific plan before you commit to anything.
More questions about getting started? The full Pelvic Floor PT FAQ covers referrals, first sessions, and what to expect.
Dr. Sarah Eichenbaum, DPT, is the owner of Pillar Core & Pelvic Floor Physical Therapy in Kirkland, WA, providing one-on-one pelvic floor and core physical therapy for women across the Eastside.