Insurance and Billing FAQs

What is the difference between a copay and coinsurance?
A copay is a fixed amount due for each visit. Coinsurance is a percentage of the amount due.  Many plans will have an 80/20 insurance/subscriber responsibility. These plans may also have a deductible attached to the plan. The deductible is met first, then the coinsurance.

What is a deductible?
This is a dollar amount that must be satisfied before other reimbursement is sent to the healthcare provider.  This may be included in your in-network plan or your out of network plan.

What is the “maximum out of pocket limit”?  
Your insurance company establishes the dollar amount that will come out of the subscriber’s pocket and then will reimburse the healthcare provider at 100% after that amount is satisfied.

What is an out of network exception or agreement?
An insurance company will contact an out of network healthcare provider and offer a contract for out of network services.  These services may include an OT Evaluation only. It also may include services (visits) after the OT Evaluation is reviewed by the insurance company.  The subscriber must contact the insurance company to initiate the process.

Does my insurance company require precertification for services?  
Many insurance companies DO require precertification for OT/PT and Speech. Before purchasing a policy or changing an employer sponsored insurance plan, do your homework. Find out what providers you currently see are enrolled in any new plan.  Ask if the new plan requires precertification for any services and if there are visit limits per calendar year.  

Document, document, document!
Whenever you speak with a healthcare provider representative, make a note of the person’s name (first and last initial) and get a call reference number. Keep accurate records of calls with the date and time of conversation.  

Does SDOT submit claim forms for services?
Yes. If the subscriber submits all necessary information, our office sends claims for both in and out of network providers.

Check out this website for NYS law regarding Healthcare in New York State

Do you accept insurance for your classes?
No, our classes are not covered by insurance as they are not therapeutic groups, but enrichment classes open to all in the community. They are designed by OTs as we have extensive knowledge of meaningful occupations and typical development across the lifespan. The classes themselves may be run by OTs as well as undergraduate and graduate students.