Ask the right questions once. Bill clean all year.
A benefits verification is not a guarantee of payment — it is only as good as the questions you ask. This is the checklist our billing team works from, including the questions most practices never think to ask.
It's a checklist, not a chat
Insurance reps answer the questions you ask — not the ones you meant to ask. Work the list top to bottom, every time, for every patient.
Turn the call into proof
Names, dates, reference numbers. A recorded call with a reference number is the difference between writing off a denial and overturning it.
Verification is not a promise
A quote from a phone rep never guarantees payment. Real eligibility is only proven when the claim pays — which is why the verification must be documented, not assumed.
Before you dial: gather the basics
The call dies fast without these in front of you. Collect them at intake, not while the rep is waiting.
Open the call with the codes
"I'm calling to verify in-network and out-of-network benefits for [patient name], date of birth [DOB], member ID [number], for occupational / physical / speech therapy in an office setting, billed under the following procedure codes: [read your code list]."
Naming the codes up front is what keeps the rep from quoting you a generic "rehabilitation benefit" that turns out not to match what you actually bill.
| Code | What it covers |
|---|---|
| Occupational Therapy | |
| 97165 / 97166 / 97167 | OT evaluation — low, moderate, high complexity |
| 97168 | OT re-evaluation |
| 97110 | Therapeutic exercise |
| 97112 | Neuromuscular re-education |
| 97140 | Manual therapy |
| 97530 | Therapeutic activities |
| 97533 | Sensory integration |
| 97535 | Self-care / ADL management |
| 97150 | Group therapy |
| 97550–97552 | Caregiver training (added in 2025) |
| Physical Therapy | |
| 97161 / 97162 / 97163 | PT evaluation — low, moderate, high complexity |
| 97164 | PT re-evaluation |
| 97110 | Therapeutic exercise |
| 97112 | Neuromuscular re-education |
| 97116 | Gait training |
| 97140 | Manual therapy |
| 97530 | Therapeutic activities |
| 97150 | Group therapy |
| 97550–97552 | Caregiver training (added in 2025) |
| Speech-Language Pathology | |
| 92521 | Evaluation of speech fluency |
| 92522 | Evaluation of speech sound production |
| 92523 | Evaluation of speech sound production with language comprehension and expression |
| 92524 | Behavioral and qualitative analysis of voice and resonance |
| 92507 | Individual speech-language treatment — valid through 12/31/2026 only |
| 92508 | Group speech-language treatment (retained in 2027) |
| 92526 | Treatment of swallowing dysfunction / oral function for feeding |
| 92610 | Evaluation of oral and pharyngeal swallowing function |
| 92597 | Evaluation for voice prosthetic device |
| 92605 / 92618 | Non-speech-generating AAC device evaluation |
| 92607 / 92608 | Speech-generating device evaluation |
| 92606 / 92609 | Therapeutic services for AAC / speech-generating devices |
| 92626 / 92627 | Evaluation of auditory function |
| 92630 / 92633 | Auditory rehabilitation |
| 96105 | Assessment of aphasia |
| 96125 | Standardized cognitive performance testing |
| 97129 / 97130 | Therapeutic interventions for cognitive function |
| 97550–97552 | Caregiver training (added in 2025) |
| GSLPP | Proposed new Medicare G code for pediatric speech-language treatment (not yet final) |
Heads up: 92507 is eliminated on 12/31/2026. Starting January 1, 2027, it is replaced by 10 new timed CPT codes — a base code (first 30 minutes) plus an add-on (each additional 15 minutes) for fluency; speech sound production; language; combined speech sound and language; and voice, upper airway, and resonance. CMS has also proposed a new G code, GSLPP, for pediatric speech-language treatment in the 2027 Medicare fee schedule; the final rule is expected in November 2026. Confirm each payer's rules before billing. | |
Coding always follows each payer's published policies and your practice's documentation. Confirm code selection with your coding team before every verification call — this list reflects codes commonly billed for outpatient therapy as of 2026, not a substitute for payer-specific rules.
The questions that protect your revenue
Ten groups, in order. For anything involving an amount, ask it twice — once for in-network, once for out-of-network.
1. Document the call
- Representative's first and last name, and their department or location.
- Date and time of the call.
- The reference or call number — this is your proof if the quote is ever disputed.
- Remember: most payer calls are recorded. The reference number is what turns a phone conversation into evidence.
2. Policy basics
- Policy effective date, and whether benefits run on a calendar year or a policy (roll-over) year.
- Who is the subscriber, and is the patient listed on the plan?
- Is the plan an HMO, PPO, EPO, or self-funded employer plan? This changes how out-of-network benefits work.
3. Coverage, per discipline
- Does the plan have an occupational therapy benefit — in-network and out-of-network?
- Does the plan have a physical therapy benefit — in-network and out-of-network?
- Does the plan have a speech-language benefit — in-network and out-of-network?
- A therapy benefit existing does not mean the service is automatically covered. Ask what conditions or settings are excluded.
4. Deductibles
- In-network deductible: individual and family amounts, and how much is already satisfied.
- Out-of-network deductible: individual and family amounts, and how much is already satisfied.
- Ask separately for each discipline — some plans apply one combined therapy deductible, others carve each discipline out.
5. Out-of-pocket maximum
- In-network out-of-pocket max: individual and family, and how much has been satisfied.
- Out-of-network out-of-pocket max: individual and family, and how much has been satisfied.
6. Co-insurance and co-pay
- Once the deductible is satisfied, what percentage does the plan pay — 50/60/70/80/90%? Ask for both in-network and out-of-network.
- If the benefit carries a co-pay instead of co-insurance, get the dollar amount per visit for each discipline.
- Does the co-pay count toward the deductible and out-of-pocket max?
7. Visit maxes
- Treatment max (visit limit) per discipline, per year — and how many visits have already been used year to date.
- Is the therapy benefit shared across disciplines (for example, a combined 30 visits across OT and speech)?
- Do visits applied to the deductible also count toward the visit max? This trips up more practices than any other question.
8. Same-day, multi-discipline visits
- Will the plan reimburse two disciplines (for example, OT and speech) on the same treatment day?
- Some payers only allow one therapy discipline per day — confirm before the family builds a two-discipline schedule.
- Ask this for both the in-network and out-of-network benefit.
9. Authorization
- Is prior authorization required for evaluation codes? For treatment codes?
- If yes: how many units or visits are approved, what date range does the authorization cover, and when does it expire?
- Who submits the authorization request — the practice or the physician? Get the submission method (portal, fax, phone).
- Record the authorization number every time.
10. The details people forget
- Is telehealth covered for therapy services, and at what rate?
- What is the timely filing limit? Mark it on your calendar the day the claim is created.
- Is there a secondary insurance? Get both ID numbers up front.
- Where do clean claims go — the payer's direct portal or a clearinghouse?
This is a daily discipline. Ours run it every business day.
Wellness Works' Eligibility & Authorization Program runs verifications, authorizations, and daily Good Faith Estimates as an add-on to core billing — custom Monday.com boards, professionally completed estimates delivered by email, and front-end intake connected directly to back-end billing. Availability depends on team capacity and it's priced separately from core billing.
