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SOLPT Guide: Do you need a referral to use insurance coverage for PT?

You call your insurance company and ask them, “Do I need a referral to get physical therapy services?”

The helpful and friendly representative on the other line states, “No! Your plan does not require a referral for physical therapy services.”

Here’s the rub. They might be totally right. They also might be utterly and completely wrong.

This blog post is going tell you when your insurance representative is right, when they’re wrong, and the best question to ask to get the information you’re really looking for.

The Difference is in the Diagnosis Code

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

Diagnosis Code. A coding system medical professionals use to classify medical conditions. This coding system is also used as a tool by insurance companies to determine coverage.

Legally, Physical Therapists are not able to make medical diagnoses. They are trained, ready, and able to get you back to movement, but making a diagnosis would literally put a physical therapist’s license in jeopardy.

Without an official medical diagnosis, we can send your claim to the insurance company. We just have to do so without a diagnosis code.

So, when your helpful and friendly insurance representative says, “You don’t need a referral to get coverage,” there’s a time when they’re absolutely right, and there’s a time when they’re stone cold wrong.

When They’re Totally Right: Direct Access

Direct Access is a law that allows anyone to access physical therapy services – without a referral – for 12 visits or 45 days (whichever comes first).

If your insurance company honors direct access, we can send them claims without a diagnosis code and they will pay the claim based solely on our CPT codes. When that insurance rep told you that you didn’t need a referral for care, this is the only case where they were 100% right!

Just a note: If you’d like to keep getting coverage for physical therapy services once the 45 days is up or once you’ve used the 12 allotted direct access visits, you will need to visit a licensed medical professional to obtain an official medical diagnosis and a referral for care.

When They’re Totally Wrong: No Direct Access

Some insurance companies do not honor direct access. In order to pay for a claim, they require a diagnosis code on the claim. No Diagnosis Code = Automatic Denial.

Your insurance may not require a referral for care, but they do require a diagnosis code to process your claim. Because physical therapists cannot diagnose your case, you will have to go to licensed medical professional who can provide you with an official medical diagnosis.

Ask a better question. Get an accurate answer.

SOLPT Referral

Your doc can even fill out this referral.

If you’re planning to use insurance to pay for physical therapy services and want to know if you need a referral or not, the following is the best question you can ask your insurance representative:

“In order for my insurance to cover physical therapy services, does my claim need to include a diagnosis code?”

If they say “Yes.”

You need a referral for care.

If they say “No.”

Most likely, this means that your insurance company honors the direct access law. For 12 sessions or 45 visits, you can see us without a medical diagnosis.

Want some help? SOL’s admin staff is here for you.

If you’re thinking about coming to SOL for services, we’re happy to give your insurance company a call, and help you understand your benefits.

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