By Brandon Seigel, Chief Problem Solver · September 18, 2026 · 5 min read
Eligibility: is the plan active?
Eligibility confirms the member is active on the dates of service. It says nothing about whether therapy is covered or how much will be paid.
Benefits: how will the plan pay?
Just because a policy lists OT, PT, or speech as a benefit doesn't mean the service is automatically covered. Benefits define deductibles, coinsurance, visit caps, shared limits, and exclusions.
Authorization: did the payer approve it?
Many plans require prior authorization for evaluations, treatment blocks, or specific codes. Without it, a fully eligible patient's claims can still be denied — often with no way to recover the visits.
Network gap exceptions
If you're out of network and the plan has no nearby in-network provider, ask whether a network gap exception is available. It can let the patient use in-network benefits with your practice. Document the process and approval.
Quick answers
What is a network gap exception?
A tool some insurers use when their network lacks contracted providers. It may allow a patient to receive in-network benefits from an out-of-network provider.
See exactly what's included in our medical billing services for therapy practices, how our percentage-of-collections pricing works, or browse common questions from practice owners.
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