Explaining out-of-network therapy benefits to patients

For OT, PT and SLP practice owners seeing children, adults or both: an out-of-network benefit is the plan paying part of a visit with a provider it has no contract with. State your network status exactly, give an accurate itemized receipt, and have the patient ask the plan. Medicare and Medicaid follow different rules.⁠^1,2,3,4

What does an out-of-network benefit pay for a therapy visit?

It pays the plan’s share of its own allowed amount, after any deductible; the patient pays their share of that amount and may also have to pay the difference between your fee and it.⁠^5,23 Out-of-network coinsurance, the patient’s share of that allowed amount, usually costs more than in-network coinsurance.⁠¹ So keep three numbers apart: your fee, the plan’s allowed amount for each code, and the patient’s share of that amount. Only the first is yours to state.

Which plan types pay anything for out-of-network therapy?

The label gives the pattern; the plan’s documents give the answer. HealthCare.gov describes an HMO as usually limiting coverage to doctors who work for or contract with it and generally covering no out-of-network care except in an emergency; an EPO as covering services only in its network, except in an emergency; a POS plan as costing less in network and requiring a referral from the primary care doctor to see a specialist; and a PPO as letting members use providers outside the network without a referral for an additional cost.⁠⁷ Those describe Marketplace plan types, not a given plan’s therapy terms, so point the patient to member services and to the plan’s Summary of Benefits and Coverage, which a member can request from the insurer.⁠^7,27

How should a therapy practice state its out-of-network status?

Plan by plan, product by product, for each clinician and address, in the same words on the phone, the website and every listing. Say “we are out of network with [plan]” rather than “we don’t take insurance,” and name any plans and products you are in network with. Check how each plan lists you first: under the No Surprises Act, a plan’s provider directory information covers individual clinicians by name, address, specialty and phone, and each group, clinic or facility contracted to participate.⁠²⁸ The credentialing guide covers participation for each clinician and location, the credentialing services guide covers paying a vendor to do it, and the insurance and fees guide covers a practice’s public insurance statement.

What happens if a plan’s directory still lists you as in network?

The patient may owe only in-network cost sharing, and the practice may owe a refund. For group health plans and individual insurance, when a patient relied on the plan’s database, directory or written answer saying a provider was participating, the plan may not charge more than in-network cost sharing and must apply the in-network deductible and out-of-pocket maximum.⁠²⁹ If the provider then bills that patient more than in-network cost sharing and the patient pays, the provider must reimburse the excess with interest.⁠²⁸

Providers must also have processes that send a plan directory information when they begin or end a network agreement and when that information materially changes.⁠²⁸ When you leave a network, send that notice in writing, keep the confirmation, and check the plan’s online directory afterward; the reimbursement rates guide covers leaving a network and the patients in care.

How should a DrSensory listing describe out-of-network status?

In the clinic’s own description, because families cannot filter the directory by insurance and the payment boxes show no network status. DrSensory is a free directory where families find OT, PT and speech therapy clinics in all 50 states and Washington, DC; it lists clinics, not individual therapists, and a basic listing costs a clinic nothing, as does claiming it.⁠³⁰ A paid listing, $29.99 a month or $349.99 a year for the first location and $9.99 a month or $99.99 a year for each additional one, adds a description in the clinic’s own words.⁠³¹

The insurance a clinic ticks in its portal shows in a paid profile’s Clinic details box, and the description is where plans are named.⁠²² Families search by ZIP code, therapy, specialty and who the care is for, and are told to check insurance with the clinic; DrSensory does not verify a clinic’s insurance or clinical quality.⁠^21,31 So an out-of-network clinic that ticks Private adds one plain sentence, such as “We are out of network with commercial plans and give an itemized receipt for your plan; we bill Medicare,” and uses it on the website and in the directory profile too.

What should a therapy superbill include for an out-of-network claim?

Everything a claims processor needs without phoning you: who treated, who bills, where, when, what, why, how much, and what was paid. A superbill is the practice’s own itemized receipt; the claim is the request for payment the patient or provider submits to the insurer, and payer instructions govern what goes with it, so ask how the plan’s members file out-of-network claims.⁠^8,9 Build it on the fields of the standard professional claim form: the NUCC’s 1500 instructions call for the diagnosis codes, dates of service, place of service code, CPT or HCPCS codes with modifiers, the charge for each line, days or units, the rendering provider’s NPI, the billing provider’s federal tax ID number, the amount paid, and the referring or ordering provider where there is one.⁠⁹

Keep every line true to the visit: the codes the documentation supports, the clinician who treated, and the fee the practice charged. Never change a code, a date or a fee to fit a patient’s benefit.

Should the practice or the patient file the out-of-network claim?

Either can, if the plan accepts it: HealthCare.gov defines a claim as a request for payment that the member or the provider submits.⁠⁸ If the practice files as a nonparticipating provider, ask the plan whether it pays the provider or the member; if the patient files, ask for the filing deadline. Put the route in the financial policy the patient signs, and settle refunds and balances from the plan’s explanation of benefits.

What should patients ask their plan about out-of-network therapy?

Whether the benefit exists for this therapy, what the plan allows, what the patient owes and which approvals come first, each answer with a reference number. The patient’s side makes the call: the adult patient, or the parent or guardian whose plan covers the child; the practice supplies the codes, its NPI and tax ID, and the questions. Preauthorization is the plan’s decision that a service is medically necessary and, HealthCare.gov notes, not a promise to pay; a referral is a written order from the primary care doctor that many HMOs require, and without a required referral the plan may not pay.⁠^32,33

How do benefit questions differ for children and adults?

For a child, they turn on the parent’s plan and its habilitative benefit; for an adult, they start with whether Medicare or Medicaid pays. HealthCare.gov describes habilitative services as helping a person keep, learn or improve skills for daily living, with therapy for a child who is not walking or talking at the expected age as an example, and rehabilitative services as restoring skills lost or impaired through illness, injury or disability; both can include PT, OT and speech-language pathology.⁠^34,35 Ask the parent to learn which benefit the plan applies and what limits it carries.

A child on Medicaid falls under Medicaid’s rules and, under 21, EPSDT, which the EPSDT guide covers; a child covered by TRICARE falls under that program, covered in the TRICARE participation guide.⁠³⁶ For an adult, ask about Medicare and Medicaid on the first call: neither works like a commercial out-of-network benefit.

Does the No Surprises Act cover out-of-network therapy visits?

Its balance-billing protections do not reach a visit a patient chooses at an independent out-of-network clinic; they cover emergency services and certain non-emergency services during a visit to an in-network facility. Under 45 CFR 149.110, a group health plan or insurer that covers emergency department services must cover emergency services without prior authorization and with no more than in-network cost sharing, even out of network.⁠¹⁰ Under 149.120, non-emergency services from a nonparticipating provider during a visit at a participating health care facility carry no more than in-network cost sharing, unless the provider met the rule’s notice-and-consent criteria.⁠¹¹ That facility is a hospital, a hospital outpatient department, a critical access hospital or an ambulatory surgical center.⁠¹²

CMS tells patients the protections do not apply in other settings, such as a doctor’s office that is not a hospital outpatient department, or at an out-of-network facility, and its provider FAQ says the federal prohibitions do not apply to non-emergency services by out-of-network providers during visits to out-of-network facilities.⁠^13,37 One case does reach therapists: a nonparticipating therapist treating patients in an in-network hospital outpatient department must not bill them more than in-network cost sharing unless the notice-and-consent criteria are met.⁠³⁸ The requirements generally apply to group health plans, individual insurance and federal employees’ plans, not to Medicare, Medicaid, Indian Health Service, VA health care or TRICARE, which CMS says have other protections.⁠³⁹

When must a therapy practice give a good faith estimate?

When an uninsured or self-pay patient schedules a service or asks about cost. Under 45 CFR 149.610, a patient is uninsured for a service if they have no benefits for it under a group health plan, individual or group insurance, a federal health care program or the federal employees’ plan, and self-pay if they have a group health plan, insurance or the federal employees’ plan but do not seek to have a claim submitted to it.⁠¹⁴ Medicare and Medicaid are not in the self-pay branch, so declining to bill either does not make a patient self-pay, but a patient with no benefits for a service under any plan or program, those two included, is uninsured for that service.⁠¹⁴

An out-of-network patient who pays your fee and plans to send the superbill to the plan sits on the line that definition draws, since the self-pay branch covers a patient who does not seek to have a claim submitted. The rule requires you to ask whether the patient is enrolled in a plan and whether they want a claim submitted; record both answers, and when they leave the status uncertain, issue the estimate.⁠¹⁴ The insurance and fees guide covers self-pay fee statements, and the family guide to adult therapy without insurance explains estimates to patients.

What can a patient do if a therapy bill exceeds the estimate?

Start patient-provider dispute resolution with HHS when one provider’s total bill is at least $400 more than that provider’s total on the estimate, postmarked within 120 calendar days of the first bill with the higher charges.⁠¹⁵ While the dispute is pending, the practice must not send the bill to collections or threaten to, should stop collection already under way, must suspend late fees, and must not retaliate.⁠¹⁵ CMS tells patients they cannot use the dispute process without an estimate.⁠⁴⁰ When a plan of care adds visits or services, re-issue the estimate; for a scheduled patient the rule requires the new one no later than 1 business day before the changed visit.⁠¹⁴

Can a therapist treat a Medicare patient out of network?

Not as commercial plans allow: therapists cannot opt out of Medicare to sign private contracts, and covered Part B services must be claimed to Medicare, with one narrow exception. Medicare’s rules let a “physician or practitioner” sign private contracts with beneficiaries for services Medicare would otherwise cover.⁠⁴¹ 42 CFR 405.400 defines a physician as a doctor of medicine, osteopathy, dental surgery or dental medicine, podiatric medicine or optometry, and a practitioner as a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical psychologist, clinical social worker, marriage and family therapist, mental health counselor, or registered dietitian or nutrition professional.⁠³

Physical therapists, occupational therapists and speech-language pathologists are in neither definition. CMS’s enrollment page lists occupational therapists, physical therapists and qualified speech-language pathologists among the providers not eligible to opt out, and Medicare’s Benefit Policy Manual says physical and occupational therapists in independent practice cannot opt out because they fall outside the opt-out law’s definition of a physician or practitioner.⁠^16,18

The claim rule does the rest. The Social Security Act requires a physician, supplier or other person to submit the claim for a Part B service paid on a fee schedule basis within 1 year, and not to charge the patient for doing so.⁠¹⁷ CMS’s manual names the one situation in which practitioners and suppliers who have not opted out need not submit a claim for a covered service: the beneficiary voluntarily refuses to authorize it, and even then Medicare’s limits on what can be collected still apply.⁠¹⁸ CMS adds that physicians and practitioners who see Medicare patients but do not want to enroll must opt out, and that a provider who sees no Medicare patients need not enroll or opt out.⁠¹⁶

So Medicare has no counterpart to the commercial out-of-network arrangement. A practice that sees Medicare patients for covered services enrolls and bills Medicare, or refers them to a clinic that does; the credentialing guide covers enrollment, and the family guide to Medicare therapy coverage covers the patient’s side.

When does an Advance Beneficiary Notice apply to therapy?

Before a service the practice expects Original Medicare to deny, when it intends to collect from the patient. CMS describes the ABN, Form CMS-R-131, as the notice given to Original Medicare beneficiaries when payment is expected to be denied, to transfer potential financial liability to them.⁠⁴² Its therapy FAQ says therapists who intend to collect directly must issue it before therapy that is or may be denied as not medically reasonable and necessary, whatever the year’s spending, such as visits after the plan-of-care goals are met; that Medicare covers therapy above the KX modifier thresholds that the therapist attests is reasonable and necessary; and that services Medicare would never cover, such as community wellness classes a PT offers, need no ABN.⁠¹⁹

For a service covered in some cases but perhaps not this one, the manual says the practice still files the claim, may collect its full charge with a proper ABN if Medicare denies it, and does not breach the claim rule when it skips the claim at the patient’s written request on an ABN.⁠¹⁸ The patient chooses: Option 1, the service with Medicare billed for a decision that can be appealed; Option 2, the service paid by the patient with no claim and no appeal; Option 3, no service.⁠⁴³ The practice delivers it before the service and early enough for an informed choice, reviews it with the patient, and never picks the option; patients with Medicare and Medicaid are told to check Option 1 and are not billed until both programs decide.⁠⁴³

How do Medicare Advantage patients fit out-of-network rules?

Through their own plan’s rules, with a ceiling for practices that have no contract. Under 42 CFR 422.214, a provider without a contract setting payment amounts for a Medicare Advantage enrollee must accept, as payment in full, what it could collect if the patient were in Original Medicare.⁠⁴⁴ A practice’s private fee does not carry over to a Medicare Advantage member; whether the plan pays out of network at all is in its plan documents, and the family guide to finding an in-network therapist covers the member’s side of a network gap.

What changes when a therapy patient has Medicaid?

Payment in full and the plan’s network rules replace the out-of-network conversation. A state must limit Medicaid participation to providers who accept, as payment in full, the agency’s payment plus any deductible, coinsurance or copayment the plan requires of the patient.⁠⁴ An enrolled practice does not bill a Medicaid patient the difference between its fee and Medicaid’s payment for a covered service; the Medicaid enrollment guide covers enrolling with the state and each plan. The rule is written about participating providers and does not address a practice that has not enrolled, so ask the state Medicaid agency in writing before accepting private payment from a Medicaid patient, and keep its answer.⁠⁴

In Medicaid managed care, a network gap works for the patient. If the network cannot provide a necessary covered service to an enrollee, the plan must cover it out of network, adequately and timely, for as long as that lasts, requiring the out-of-network provider to coordinate payment with the plan and keeping the enrollee’s cost no greater than in network.⁠²⁰ Agree the authorization and the rate with the plan in writing before the first visit.

What are network gap exceptions and single case agreements?

They are how a plan pays an out-of-network practice on in-network terms for one patient its network cannot serve: a coverage decision by the plan, sometimes with a contract between the plan and the practice. In defining a participating facility, the No Surprises Act rules describe a single case agreement as one used for unique situations in which a patient requires services that typically occur out of network, and treat it as a contractual relationship limited to its parties.⁠¹² For Medicaid managed care, the obligation to cover out of network is in regulation.⁠²⁰ For other plans, the plan’s documents decide, so ask what the plan calls the process and how it starts; the family guide to finding an in-network therapist gives patients a search log and a request letter.

Before the first visit under any such arrangement, get these terms from the plan in writing:

• The patient, plan and member ID, and the authorization or agreement number.
• The services by code, the number of visits or units, and the dates covered.
• The rate for each code, stated as a fixed amount or as a share of the plan’s allowed amount.
• The patient’s cost sharing, and whether the practice may bill anything beyond it.
• Who files the claims, where, with which modifiers or notes, and by what date.
• How to extend the agreement, and what happens if the clinician or location changes.

Where does a patient appeal a denied out-of-network claim?

With the plan first, then an outside reviewer that depends on how the plan is funded and regulated. Under 45 CFR 147.136, group health plans and insurers must run an internal claims and appeals process; group plans and their insurers follow the Labor Department’s ERISA claims rule at 29 CFR 2560.503-1, and an individual-market insurer follows it with one level of internal appeal.⁠⁴⁵ For external review, an insurer bound by a state process that meets the rule’s minimum consumer protections follows the state’s; a self-insured plan follows a state process where one applies and binds it, for example where ERISA does not preempt it; and a plan or insurer with no applicable state process uses the federal one.⁠⁴⁵ HealthCare.gov tells members they can appeal a refused claim and have it reviewed by a third party.⁠⁴⁶

The practice supplies the record: the plan of care, progress notes, a letter on why the therapy is needed, a corrected superbill if a code or date was wrong, and any explanation of benefits it received. Have the patient ask the employer’s benefits office whether the plan is insured or self-funded. The family guide to appealing a therapy denial walks patients through the steps; Medicare appeals are in the Medicare therapy coverage guide.

How do you explain out-of-network benefits by plan type?

Match the explanation to what the plan type pays out of network, then let the plan’s own documents settle the details. Keep the last column on the front desk’s screen.

What does out-of-network therapy look like for a family and an adult?

Both run on the same sequence: state your status, hand over the questions, let the plan answer, and document what happened. The figures are inputs for the examples, not typical fees or plan terms.

Sources

1. HealthCare.gov. Out-of-network coinsurance (glossary). “The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don’t contract with your health insurance or plan.”; “Out-of-network coinsurance usually costs you more than in-network coinsurance.”. Checked October 25, 2026.
2. HealthCare.gov. Network (glossary). “The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.”. Checked October 25, 2026.
3. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 405.400, Definitions (opting out of Medicare and private contracts) (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
   Show the passageHide the passage

   “Physician means a doctor of medicine; doctor of osteopathy; doctor of dental surgery or of dental medicine; doctor of podiatric medicine; or doctor of optometry who is legally authorized to practice medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, or optometry by the State in which he performs such function”; “Practitioner means a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical psychologist, clinical social worker, marriage and family therapist, mental health counselor, registered dietitian or nutrition professional, who is currently legally authorized to practice in that capacity by each State in which he or she furnishes services to patients or clients.”; “Private contract means a document that meets the criteria specified in § 405.415.”.
4. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 447.15, Acceptance of State payment as payment in full (Medicaid) (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
   Show the passageHide the passage

   “A State plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual.”.
5. HealthCare.gov. Allowed amount (glossary). “The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.””; “If your provider charges more than the plan’s allowed amount, you may have to pay the difference.”. Checked October 25, 2026.
6. HealthCare.gov. Balance billing (glossary). “When a provider bills you for the difference between the provider’s charge and the allowed amount.”; “A preferred provider may not balance bill you for covered services.”. Checked October 25, 2026.
7. HealthCare.gov. Health insurance plan & network types: HMOs, PPOs, and more (Marketplace plan types). Checked October 25, 2026.
   Show the passageHide the passage

   “Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).”; “Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency.”; “Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.”; “Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.”.
8. HealthCare.gov. Claim (glossary). “A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.”. Checked October 25, 2026.
9. National Uniform Claim Committee. 1500 Health Insurance Claim Form Reference Instruction Manual for Form Version 02/12 (Version 13.0, July 2025). Checked October 25, 2026.
   Show the passageHide the passage

   Items 21, 24A, 24B, 24D, 24F, 24G, 24J, 25, 29 and 17: “Enter the codes left justified on each line to identify the patient’s diagnosis or condition.”; “Enter date(s) of service, both the “From” and “To” dates.”; “The “Place of Service” Code identifies the location where the service was rendered.”; “Enter the CPT or HCPCS code(s) and modifier(s) (if applicable) from the appropriate code set in effect on the date of service.”; “Enter the charge amount for each listed service.”; “Enter the number of days or units.”; “Enter the NPI number in the unshaded area of the field.”; “Enter the “Federal Tax ID Number” (employer ID number or SSN) of the Billing Provider identified in Item Number 33.”; “Enter total amount the patient and/or other payers paid on the covered services only.”; “Enter the name (First Name, Middle Initial, Last Name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim.”; “Any user of this document should refer to the most current federal, state, or other payer instructions for specific requirements applicable to using the 1500 Claim Form.”.
10. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 149.110, Preventing surprise medical bills for emergency services (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “the plan or issuer must cover emergency services”; “Without the need for any prior authorization determination, even if the services are provided on an out-of-network basis.”; “Without imposing cost-sharing requirements that are greater than the requirements that would apply if the services were provided by a participating provider or a participating emergency facility.”.
11. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 149.120, Preventing surprise medical bills for non-emergency services performed by nonparticipating providers at certain participating facilities (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “items and services (other than emergency services) furnished to a participant, beneficiary, or enrollee by a nonparticipating provider with respect to a visit at a participating health care facility, unless the provider has satisfied the notice and consent criteria of § 149.420(c) through (i) with respect to such items and services.”; “Must not impose a cost-sharing requirement for the items and services that is greater than the cost-sharing requirement that would apply if the items or services had been furnished by a participating provider.”.
12. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 149.30, Definitions (surprise billing and transparency requirements) (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “Health care facility, with respect to a group health plan or group or individual health”; “in the context of non-emergency services, is each of the following:”; “A hospital (as defined in section 1861(e) of the Social Security Act);”; “A hospital outpatient department;”; “A critical access hospital (as defined in section 1861(mm)(1) of the Social Security Act); and”; “An ambulatory surgical center described in section 1833(i)(1)(A) of the Social Security Act.”; “A single case agreement between a health care facility and a plan or issuer that is used to address unique situations in which a participant, beneficiary, or enrollee requires services that typically occur out-of-network constitutes a contractual relationship for purposes of this definition, and is limited to the parties to the agreement.”; “includes, in addition to items and services furnished by a provider at the facility, equipment and devices, telemedicine services, imaging services, laboratory services, and preoperative and postoperative services”.
13. Centers for Medicare & Medicaid Services. Know your medical bill rights when using insurance (No Surprises Act consumer page; page last modified October 1, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “You’re protected from out-of-network charges when you get care related to a visit to an in-network:”; “These protections don’t apply at other settings (like a doctor’s office that isn’t a hospital outpatient department), or if you go to an out-of-network facility.”; “Signing the notice and consent form is your choice. You might choose to go out-of-network if you prefer a provider that isn’t in-network.”.
14. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 149.610, Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    (a)(2)(xiii)(A) and (B), (b)(1)(ii) to (vi), (b)(1)(vii), (b)(1)(x), (c)(1), (e)(1) and (f)(1): “An individual who does not have benefits for an item or service under a group health plan, group or individual health”; “Federal health care program (as defined in section 1128B(f) of the Social Security Act), or a health benefits plan under chapter 89 of title 5, United States Code; or”; “but who does not seek to have a claim for such item or service submitted to such plan or coverage.”; “Inquiring whether an individual who is enrolled in a group health plan”; “is seeking to have a claim submitted for the primary item or service with such plan or coverage; and”; “Written in a clear and understandable manner, prominently displayed (and easily searchable from a public search engine) on the convening provider’s or convening facility’s website, in the office, and on-site where scheduling or questions about the cost of items or services occur;”; “Orally provided when scheduling an item or service or when questions about the cost of items or services occur; and”; “Convening providers and convening facilities shall consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate;”; “When a primary item or service is scheduled at least 3 business days before the date the item or service is scheduled to be furnished: Not later than 1 business day after the date of scheduling;”; “When a primary item or service is scheduled at least 10 business days before such item or service is scheduled to be furnished: Not later than 3 business days after the date of scheduling; or”; “When a good faith estimate is requested by an uninsured (or self-pay) individual: Not later than 3 business days after the date of the request.”; “a new good faith estimate must be issued to the uninsured (or self-pay) individual no later than 1 business day before the items or services are scheduled to be furnished.”; “The scope of a good faith estimate for recurring primary items or services must not exceed 12 months.”; “the expected scope of the recurring primary items or services (such as timeframes, frequency, and total number of recurring items or services)”; “Patient name and date of birth;”; “Description of the primary item or service in clear and understandable language”; “Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;”; “Name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the good faith estimate, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility;”; “A disclaimer that the good faith estimate is not a contract”; “A good faith estimate must be provided in written form either on paper or electronically, pursuant to the uninsured (or self-pay) individual’s requested method of delivery”; “is considered part of the patient’s medical record and must be maintained in the same manner as a patient’s medical record.”; “must provide a copy of any previously issued good faith estimate furnished within the last 6 years to an uninsured (or self-pay) individual upon the request of the uninsured (or self-pay) individual.”.
15. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 149.620, Requirements for the patient-provider dispute resolution process (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “Substantially in excess means, with respect to the total billed charges by a provider or facility, an amount that is at least $400 more than the total amount of expected charges listed on the good faith estimate for the provider or facility.”; “postmarked within 120 calendar days of receiving the initial bill containing charges for the item or service that is substantially in excess of the expected charges in the good faith estimate.”; “While the patient-provider dispute resolution process is pending, the provider or facility must not move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider or facility should cease collection efforts.”; “The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded.”; “The provider or facility must not take or threaten to take any retributive action against an uninsured (or self-pay) individual for utilizing the patient-provider dispute resolution process”.
16. Centers for Medicare & Medicaid Services. Manage Your Enrollment (page last modified March 4, 2026; section Opt Out of Medicare). Checked October 25, 2026.
    Show the passageHide the passage

    “Physicians and practitioners who see Medicare patients but don’t want to enroll in the Medicare program must opt-out of Medicare.”; “If you don’t see Medicare patients, you don’t have to enroll in or opt-out of Medicare.”; “Enter into a private contract with each of your Medicare patients.”; “Providers NOT Eligible to Opt Out”; “Occupational therapists”; “Physical therapists”; “Qualified speech language pathologists”.
17. United States Code. 42 U.S.C. §1395w-4, Payment for physicians’ services (U.S. Code, 2024 edition; Social Security Act §1848). Checked October 25, 2026.
    Show the passageHide the passage

    (g)(4)(A), Physician submission of claims: “For services furnished on or after September 1, 1990, within 1 year after the date of providing a service for which payment is made under this part on a reasonable charge or fee schedule basis, a physician, supplier, or other person”; “shall complete and submit a claim for such service on a standard claim form specified by the Secretary to the carrier on behalf of a beneficiary, and”; “may not impose any charge relating to completing and submitting such a form.”.
18. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; sections 40, 40.4 and 40.19). Checked October 25, 2026.
    Show the passageHide the passage

    “Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B.”; “The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare.”; “However, the limits on what the physician, practitioner, or other supplier may collect from the beneficiary continue to apply to charges for the covered service, notwithstanding the absence of a claim to Medicare.”; “Physical therapists in independent practice and occupational therapists in independent practice cannot opt out because they are not within the opt out law’s definition of either a “physician” or “practitioner”.”; “a non-opt-out physician/practitioner or other supplier is not relieved of his or her obligation to file a claim with Medicare.”; “If the physician or practitioner or other supplier has given a proper Advance Beneficiary Notice (ABN), he or she may collect from the beneficiary the full charge if Medicare does deny the claim.”; “Providers and suppliers will not violate the mandatory claim submission rules of §1848(g)(4) of the Social Security Act when a claim is not submitted per a beneficiary’s written request on an ABN.”.
19. Centers for Medicare & Medicaid Services. Outpatient Therapy Services and Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 (frequently asked questions, August 2018; its dollar thresholds are those of 2018). Checked October 25, 2026.
    Show the passageHide the passage

    “Therapists and therapy providers that intend to collect from beneficiaries directly are required to issue the ABN to original (fee-for–service) Medicare beneficiaries prior to providing therapy that is or may be denied as not medically reasonable and necessary regardless of the amount of incurred expenses.”; “currently, he has achieved all his PT goals established in the plan of care (POC).”; “No, Medicare covers therapy services above the -KX modifier thresholds for which the therapist or therapy provider attests are medically reasonable and necessary.”; “An ABN is not needed for services that Medicare would never cover.”; “The patient then opted to pay out-of-pocket for Tai Chi classes her PT offers as part of her Wellness Programs that are open to other community members.”.
20. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 438.206, Availability of services (Medicaid managed care) (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    (b)(4) and (b)(5): “If the provider network is unable to provide necessary services, covered under the contract, to a particular enrollee, the MCO, PIHP, or PAHP must adequately and timely cover these services out of network for the enrollee, for as long as the MCO, PIHP, or PAHP’s provider network is unable to provide them.”; “Requires out-of-network providers to coordinate with the MCO, PIHP, or PAHP for payment and ensures the cost to the enrollee is no greater than it would be if the services were furnished within the network.”.
21. DrSensory. Find a therapist (the directory search). “Enter your ZIP code, what you need, the specialty, and who it is for.”; “check credentials, licensure and insurance with the clinic.”; “inclusion does not mean we have verified a provider’s credentials, licensure, or insurance.”. Checked October 25, 2026.
22. DrSensory. Claim and optimize your DrSensory profile (the guide for clinics). “The languages you speak and the insurance you take appear in a paid profile’s Clinic details box once you fill them in”; “The Clinic details box shows the boxes you tick; the description is where you name the plans.”. Checked October 25, 2026.
23. HealthCare.gov. Deductible (glossary). “The amount you pay for covered health care services before your insurance plan starts to pay.”; “Some plans have separate deductibles for certain services, like prescription drugs.”. Checked October 25, 2026.
24. HealthCare.gov. UCR (usual, customary, and reasonable) (glossary). “The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service.”; “The UCR amount sometimes is used to determine the allowed amount.”. Checked October 25, 2026.
25. HealthCare.gov. Out-of-network copayment (glossary). “A fixed amount (for example, $30) you pay for covered health care services from providers who don’t contract with your health insurance or plan.”; “Out-of-network copayments usually are more than in-network copayments.”. Checked October 25, 2026.
26. HealthCare.gov. Out-of-pocket maximum/limit (glossary). “The most you have to pay for covered services in a plan year.”; “The out-of-pocket limit doesn’t include:”; “Out-of-network care and services”; “Costs above the allowed amount for a service that a provider may charge”. Checked October 25, 2026.
27. HealthCare.gov. Summary of Benefits and Coverage (SBC) (glossary). “An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans.”; “request an SBC from the health insurance company”. Checked October 25, 2026.
28. United States Code. 42 U.S.C. §300gg-139, Provider requirements to protect patients and improve the accuracy of provider directory information (U.S. Code, 2024 edition; Public Health Service Act §2799B-9, added by the No Surprises Act). Checked October 25, 2026.
    Show the passageHide the passage

    “each health care provider and each health care facility shall have in place business processes to ensure the timely provision of provider directory information to a group health plan or a health insurance issuer”; “when the provider or facility begins a network agreement with a plan or with an issuer with respect to certain coverage;”; “when the provider or facility terminates a network agreement with a plan or with an issuer with respect to certain coverage;”; “when there are material changes to the content of provider directory information”; “the provider shall reimburse the enrollee for the full amount paid by the enrollee in excess of the in-network cost-sharing amount for the treatment or services involved, plus interest”; “includes the names, addresses, specialty, telephone numbers, and digital contact information of individual health care providers, and the names, addresses, telephone numbers, and digital contact information of each medical group, clinic, or facility contracted to participate”.
29. United States Code. 42 U.S.C. §300gg-115, Protecting patients and improving the accuracy of provider directory information (U.S. Code, 2024 edition; Public Health Service Act §2799A-5, added by the No Surprises Act). Checked October 25, 2026.
    Show the passageHide the passage

    (b)(1)(A), (b)(1)(B) and (b)(2)(A): “shall not impose on such participant, beneficiary, or enrollee a cost-sharing amount for such item or service so furnished that is greater than the cost-sharing amount that would apply under such plan or coverage had such item or service been furnished by a participating provider; and”; “shall apply the deductible or out-of-pocket maximum, if any, that would apply if such services were furnished by a participating provider or a participating facility.”; “received through a database, provider directory, or response protocol described in subsection (a) information with respect to such item and service to be furnished and such information provided that the provider was a participating provider”.
30. DrSensory. DrSensory for therapists (the For Therapists hub). Checked October 25, 2026.
    Show the passageHide the passage

    “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “across all 50 states and Washington, DC.”; “Every clinic keeps a basic listing at no cost.”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “Claiming is free and has three steps: find your listing, confirm your email with a six-digit code, choose a password.”.
31. DrSensory. Therapy Clinic Directory Pricing (the pricing page and its frequently asked questions). Checked October 25, 2026.
    Show the passageHide the passage

    “$29.99 a month or $349.99 a year for your first location, and $9.99 a month or $99.99 a year for each additional location”; “A description in your own words”; “We do not verify clinical quality.”; “We do not sell your leads.”; “Featured city placement is a separate option, coming soon.”.
32. HealthCare.gov. Preauthorization (glossary). “A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.”; “Preauthorization isn’t a promise your health insurance or plan will cover the cost.”. Checked October 25, 2026.
33. HealthCare.gov. Referral (glossary). Checked October 25, 2026.
    Show the passageHide the passage

    “A written order from your primary care doctor for you to see a specialist or get certain medical services.”; “In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor.”; “If you don’t get a referral first, the plan may not pay for the services.”.
34. HealthCare.gov. Habilitative/Habilitation services (glossary). Checked October 25, 2026.
    Show the passageHide the passage

    “Health care services that help you keep, learn, or improve skills and functioning for daily living.”; “Examples include therapy for a child who isn’t walking or talking at the expected age.”; “These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.”.
35. HealthCare.gov. Rehabilitative/Rehabilitation services (glossary). “Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled.”; “These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.”. Checked October 25, 2026.
36. Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment (the EPSDT benefit). Checked October 24, 2026.
    Show the passageHide the passage

    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state’s Medicaid plan. It is the responsibility of states to determine medical necessity on a case-by-case basis.”.
37. Centers for Medicare & Medicaid Services. Frequently Asked Questions for Providers About the No Surprises Rules (April 6, 2022; question 9). Checked October 25, 2026.
    Show the passageHide the passage

    “The federal balance billing prohibitions don’t apply to non-emergency services provided by out-of-network providers during patient visits to out-of-network facilities.”; “In this setting, the provider does not need to obtain the patient’s consent to bill them directly, or balance bill them.”.
38. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 149.420, Balance billing in cases of non-emergency services performed by nonparticipating providers at certain participating health care facilities (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “A nonparticipating provider of a group health plan or group or individual health”; “at a participating health care facility must not bill, and must not hold liable, a participant, beneficiary, or enrollee of such plan or coverage for a payment amount for such an item or service furnished by such provider with respect to a visit at the facility that exceeds the cost-sharing requirement for such item or service”; “unless the provider (or the participating health care facility on behalf of the provider) satisfies the notice and consent criteria of paragraph (c) of this section.”.
39. Centers for Medicare & Medicaid Services. Provider requirements and resources (No Surprises rules; page last modified August 20, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “These requirements generally apply to items and services provided to consumers enrolled in group health plans, group or individual health”; “and Federal Employees Health Benefits plans.”; “These requirements don’t apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs have other protections against high medical bills.”.
40. Centers for Medicare & Medicaid Services. Know your medical bill rights when not using insurance (No Surprises Act consumer page; page last modified October 5, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “This applies when you don’t have insurance, or are choosing not to use it.”; “You may choose not to use insurance if the service you need isn’t covered, or it’s less expensive if you pay out of pocket.”; “You can’t use the No Surprises Act dispute process without an estimate.”.
41. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 405.405, General rules (opting out of Medicare and private contracts) (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “A physician or practitioner may enter into one or more private contracts with Medicare beneficiaries for the purpose of furnishing items or services that would otherwise be covered by Medicare, provided the conditions of this subpart are met.”; “Services furnished under private contracts meeting the requirements of this subpart are not covered services under Medicare”.
42. Centers for Medicare & Medicaid Services. FFS ABN (Beneficiary Notices Initiative, page last modified July 17, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where Medicare payment is expected to be denied.”; “The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances.”.
43. Centers for Medicare & Medicaid Services. Form Instructions, Advance Beneficiary Notice of Non-coverage (ABN) (OMB Approval Number 0938-0566). Checked October 25, 2026.
    Show the passageHide the passage

    “Deliver the ABN to the patient or their representative before providing the items or services;”; “Review the ABN with the patient or their representative and answer any questions before it’s signed;”; “Deliver the ABN far enough in advance that the patient or representative has time to consider the options and make an informed choice;”; “This option allows the patient to get the items and/or services and requires the notifier to submit a claim to Medicare. This will result in a payment decision that can be appealed.”; “No claim will be filed, and Medicare won’t be billed, so there are no appeal rights.”; “the patient understands that the items or services won’t be provided, so there are no appeal rights.”; “the notifier must not decide for the patient which of the 3 options to select.”; “Dually eligible patients must be instructed to check Option Box 1 on the ABN for a claim to be submitted for Medicare adjudication.”; “Providers must not bill the patient until adjudication by both Medicare and Medicaid”.
44. Office of the Federal Register, Electronic Code of Federal Regulations. 42 CFR 422.214, Special rules for services furnished by noncontract providers (Medicare Advantage) (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “Any provider (other than a provider of services as defined in section 1861(u) of the Act) that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.”.
45. Office of the Federal Register, Electronic Code of Federal Regulations. 45 CFR 147.136, Internal claims and appeals and external review processes (regulation; eCFR text up to date as of October 22, 2026). Checked October 25, 2026.
    Show the passageHide the passage

    “A group health plan and a health insurance issuer offering group or individual health”; “must implement an effective internal claims and appeals process”; “must comply with all the requirements applicable to group health plans under 29 CFR 2560.503-1”; “must provide for only one level of internal appeal before issuing a final determination.”; “then the issuer must comply with the applicable State external review process and is not required to comply with the Federal external review process of paragraph (d) of this section.”; “A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process”; “(that is, the plan is self-insured) and is subject to a State external review process that applies to and is binding on the plan (for example, is not preempted by ERISA)”.
46. HealthCare.gov. Appeal (glossary). “A request for your health insurance company or the Health Insurance Marketplace® to review a decision that denies a benefit or payment.”; “If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.”. Checked October 25, 2026.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. Each plan’s own documents decide what it pays out of network, and its examples are hypothetical, not DrSensory data or benchmarks.