Insurance Benefit Worksheet

MPTC will make every effort to obtain benefit information for you from your insurance company. This information is obtained in a good-faith effort and is not ever a guarantee of payment. However, before beginning therapy services, or if you have had a change in insurance providers/plans, we strongly encourage you to call your insurance provider and understand your benefit coverage and financial responsibilities.

Insurance coverage for therapies varies widely between insurance providers and it is important to never assume that therapy will be covered. It is the insurance company that makes the final determination of your eligibility and benefits. Below are some key questions to ask when checking your insurance coverage for therapy. If you have any questions or concerns about your coverage, please don’t hesitate to email info@minnetonkatherapy.com or call our billing specialist Holly Lottman at 218-297-1020.

MPTC Tax ID: 26-0254627

MPTC NPI: 1891998035

*Important: Make sure that you ask for HABILITATIVE therapy benefit information, NOT rehabilitative.

Patient Name

Date of Birth

Date you called:

Reference number for call:

Name of the representative you spoke with:

Is Minnetonka Pediatric Therapy Center an In-Network provider for me?

Yes No

Does my policy have coverage for habilitative (speech, occupational, or physical) therapy?

Yes No

Does my policy require a referral from my physician?

Yes No

Do I have a co-payment per visit?

Yes No

If yes, how much?

Will visits be applied to a deductible?

How much is the deductible (individual and family)?

How much of my deductible have I met this year?

Do I have a co-insurance?

Yes No

What percentage of the visit charges will I be responsible for?

How much is my out-of-pocket max?

Does my plan require prior authorization?

Yes No

Is there a visit limit?

Yes No

How many visits are allowed?

Is the visit limit per calendar year or plan year?

Calendar year Plan year

If there is a visit limit, is it shared between multiple therapies (i.e. PT/OT/Chiro, etc.)?

Yes No

Are there any exclusions for developmental delay?

Yes No

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