How to Get Reimbursed by your Insurance for Out-of-Network Pediatric Physical Therapy
When it comes to your child’s development, every decision feels significant—especially those that impact their health and growth. One such choice parents face is whether to stay within the confines of their insurance network or explore care options beyond it. While “out-of-network” might sound expensive or unnecessary at first, there are many reasons why choosing an out-of-network pediatric physical therapist (PT) can actually be a wise investment in your child’s well-being.
The benefits of seeing an out of network provider are described in this previously written blog post. Head over there to get a good understanding of why it is truly beneficial and may be a better choice for your family.
Choosing an out-of-network pediatric physical therapist can offer your child specialized, personalized care—but it often means you’re paying out of pocket. The good news? Many insurance plans do offer partial reimbursement for out-of-network services. It just takes a bit of extra paperwork and patience.
Here’s a step-by-step guide to help you navigate the reimbursement process and make the most of your out-of-network benefits.
1. Check Your Insurance Plan for Out-of-Network Coverage
Start by logging into your insurance portal or by calling the member services number on the back of your insurance card and ask the following:
• Do I have out-of-network benefits for physical therapy?
• Is pediatric physical therapy covered out of network?
• What is my out-of-network deductible? Has any of it been met?
• What percentage of the service fee will be reimbursed after the deductible is met (this is called coinsurance)?
• Is pre-authorization or a physician’s referral required?
2. Pay the Provider Directly and Get a Superbill
Since out-of-network providers don’t bill insurance directly, you’ll pay them upfront. In return, ask for a superbill, which is an itemized receipt containing the information your insurance company needs to process a reimbursement.
A proper superbill should include:
• Provider’s name, credentials, NPI (National Provider Identifier), and tax ID number
• Your child’s name and date of birth
• Date of each session
• CPT (billing) codes for each service provided
• Diagnosis codes (ICD-10)
• Total amount paid
• Payment method
• Office address and contact information
3. Fill Out a Claim Form and/or Submit the Superbill
Most insurance companies require a claim form to accompany your superbill. You can usually download and submit this form from your insurer’s website.
Sometimes insurances will allow you to simply attach the superbill and send it directly. Other times you will need to fill out their form with information from the superbill from your provider.
Pro tip: Send claims as soon as possible. Most insurers have a deadline (often 90–180 days from the date of service).
4. Track Your Claim and Follow Up
Once submitted, follow up within 2–3 weeks to confirm that your claim was received and is being processed. Ask:
• Has the claim been approved or denied?
• When will the reimbursement check be sent?
• Is additional documentation needed?
If your claim is denied, don’t panic. You have the right to appeal, and many denials can be overturned with a little persistence and clarification. In my experience, insurances like to deny a claim stating that some information is missing from the superbill when it is in fact not missing. It can take a few repetitions to get these claims to go through. Be persistent!
5. Use HSA or FSA Funds if Available
If you have a Health Savings Account (HSA) or Flexible Spending Account (FSA), you can often use these funds to pay for out-of-network therapy—even if your insurance denies the claim. Keep receipts and superbills for your records in case of an IRS audit.
What If You’re Not Sure Where to Start?
Ask your pediatric physical therapist! Many out-of-network providers are experienced in helping families with the reimbursement process and can guide you.
