A Brief Guide to Insurance Language

Please call your insurance’s customer service number to ensure you fully understand your benefits and coverage, and remember it is ultimately your responsibility to know the limits of your insurance and your financial responsibility.

Prior Authorization: After your initial evaluation, Play Works’ Patient Care Coordinator will submit a prior authorization to your insurance. The medical reviewer at your insurance company will decide whether or not to approve the request based on what they think is medically necessary. Once visits are approved we are able to schedule recurring appointments.

All authorizations have a start date, an expiration date, and a total number of visits approved. If an authorization expires before we have used all the visits, we will need to resubmit for reapproval. Even if your insurance approves visits, this does not necessarily mean your care is fully covered. Approved visits just mean that your insurance is giving you permission to use your benefits, and that you are financially liable for what is not covered.

Copay: A copay is due at the time of service. This amount typically varies from $10-$40, depending on your plan and whether services at Play Works are deemed “specialist” or “professional” by your insurance.

Deductible: If you have a deductible, this is the amount of money you will need to pay for services before insurance will pay for anything. This means you will owe the complete cost of each service until your deductible is met - most families who do this will meet their deductible in no more than one month of regularly receiving services at Play Works. This will go on until the deductible is met, after which point you may have to pay a coinsurance.

Coinsurance: After a deductible is met your coinsurance kicks in. This means that once the deductible is reached your insurance starts picking up some of the costs. A typical in-network coinsurance is 20%, meaning you would be picking up the remaining 20% that insurance didn't cover. Out of network is usually 50% coinsurance. This all depends on the plan you have chosen.

A co-insurance is different from a copay. If your family has a coinsurance you do not pay anything at the time of service, and instead will wait until the claim processes and then you will be invoiced for what you owe.

Out of Pocket Max (OPM): Sometimes the deductible and OPM are tied together, in which case whatever is met on the deductible applies to the OPM as well. It is very rare to meet both the deductible and OPM, as it’s typically a lot of money, but once both have been met within one calendar year services are covered at 100%.