What is benefit language?

Benefit language defines who is eligible to receive care, how much care they can receive, and in what time period the care can be rendered. The language can either be very restrictive or all-inclusive. For instance, a health plan’s physical therapy benefit may limit treatment of chronic, or long-term, conditions by a physical therapist, which could restrict patients diagnosed with cerebral palsy, multiple sclerosis, or rheumatoid arthritis from receiving physical therapy services.

Some plans may place a cap on the maximum number of physical therapy visits a patient may have available (for example, 15 visits) and may specify that the visits be rendered within a specific time period (for example, 90 calendar days). It is important to read the physical therapy benefit language carefully to know if the visit limit is “per condition,” “per calendar year,” or “per episode of care.”

Other plans may permit only a small number of visits for any condition, after which “pre-authorization” from the payer for further visits is required. Some managed care organizations use primary care physicians as “gatekeepers.” In this model, the primary care physicians have to approve visits to a PT and must complete the necessary referral papers prior to treatment. In addition, some health plans may require that their own utilization management department review each case to decide if the medical necessity has been supported by the documentation.

 provided courtesy of APTA

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