Experience Momentum’s Benefit Guide
Navigating insurance and understanding your benefits can be confusing, which is why we created an Insurance Benefit Guide as a resource for our patients. This is intended to be a helpful guide in checking your insurance plan's benefits and understanding how they may apply for our services. These questions are specific to each of our clinical services and will hopefully give you a better understanding of your insurance coverage so you can stay informed and make the best decisions for your care.
Follow these steps:
Find a member services number on the back of your insurance card.
Have your insurance card ready and be sure to note the reference number and date of your call.
Select the service you are calling about below and ask the questions listed to understand your coverage.
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Ask the following questions:
Is Physical Therapy eligible under my benefit plan?
What is my benefit calendar year? When will my plan reset?
How many visits are allowed per benefit year?
Do I need to meet a deductible before insurance begins paying my claims? If yes, how much is it?
Will I have to pay a copay or coinsurance for each visit?
Is a referral or pre-authorization required for Physical Therapy services?
Are telehealth Physical Therapy services covered under my plan?
Common CPT/Procedure Codes:
97110 – Therapeutic Exercise
97530 – Therapeutic Activities
97112 – Neuromuscular Re-education
97140 – Manual Therapy
20560 & 20561 – Dry Needling
For your reference our Billing NPI is: 1639414766
Please note, initial evaluations typically use separate codes and may be higher in cost.
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Note: Experience Momentum only provides massages by Licensed Massage Therapists
Ask the following questions:
Is Massage Therapy an eligible service under my benefit plan?
What is my benefit calendar year? When will my plan reset?
How many visits are allowed per benefit year?
Do I need to meet a deductible before insurance begins paying my claims? If yes, how much is it?
Will I have to pay a copay or coinsurance for each visit?
Is a referral or pre-authorization required for Massage Therapy services?
Does my plan allow for Massage Therapy services if rendered by a Licensed Massage Therapist (LMT)?
Common CPT/Procedure Codes:
97124 – Therapeutic Massage
For your reference our Billing NPI is: 1639414766
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Ask the following questions:
Is Nutritional Counseling/Therapy eligible under my benefit plan as a preventative benefit?
Is this service eligible under my plan, and are there specific criteria or diagnosis codes required to qualify?
Is Nutrition counseling covered as a medical benefit?
If yes, are there any diagnosis codes excluded from coverage?
Are telehealth Nutrition services covered under my plan?
What is my benefit calendar year? When will my plan reset?
How many visits are allowed per benefit year?
Do I need to meet a deductible before insurance begins paying?
Will I have to pay a copay or coinsurance for each visit?
Is a referral or pre-authorization required for Nutrition counseling?
Common CPT/Procedure Codes:
97802 – Initial Assessment
97803 – Follow-up Visit
For your reference our Billing NPI is: 1639414766
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Good to Know before getting started:
What is a CPT code?
The Current Procedural Terminology (CPT®) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.
Why do I need to provide it?
If provided to your insurance, they may be able to give you pricing information for certain medical procedures or services.
What is a a Billing NPI?
A Billing NPI is a unique identification number used to identify a healthcare provider or organization.
Common Definitions:
Co-Insurance: A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid.
Copay: A form of medical cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received. The insurer is responsible for the rest of the reimbursement.
Deductible: A fixed dollar amount during the benefit period, usually a year, that an insured person pays before the insurer starts to make payments for covered medical services. Plans may have both per individual and family deductibles.
Out-of-Pocket Maximum: The maximum dollar amount a group member is required to pay out of pocket during a year. Until this maximum is met, the plan and group member shares in the cost of covered expenses. After the maximum is reached, the insurance carrier pays all covered expenses, often up to a lifetime maximum.
Pre-Authorization:Healthcare.gov defines prior authorization as “approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan”. The general process has many names including precertification, pre-authorization, prior approval, and predetermination.
Contracted Rates:The amount that an insurance company will pay for a given service code according to the contract. This applies to providers that are in-network with a specific payer.