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Great Plains Therapy
Insurance

Insurance TERMINOLOGY


Here are some terms that you may encounter on your explanation of benefits (EOB) that you receive from your insurance company.

Definition of Terms:

Amount Charged
The total amount charged by a healthcare provider for services you received, whether or not the services are covered under your health plan.

Amount Not Covered: 
The portion of the charged not covered under your health plan.  Examples of Amounts Not Covered include any of the following:

  • Amounts of services that are not medically necessary.
  • Amounts for services that are not covered by your health plan.
  • Amounts for services that have reached contract or benefit maximums.
  • If you receive services from a non-participating health care provider, any difference between the Amount Charged and the maximum allowable fee for the service.  Maximum allowable fee is the amount we establish for covered services or supplies.

Amount Paid By Health Plan:
 The amount paid to you or your health care provider.

Co-insurance: 
The amount, calculated using a fixed percentage, you pay for certain services.  Your health provider may bill you for these charges. 

Copayment: 
The fixed dollar amount you pay for certain covered services.  Your health care provider may require this payment when you receive services.

Deductible: 
The fixed dollar amount you pay for covered services before benefits are available.  Your health care provider may bill you for these charges.

Network Savings:
The amount you saved by receiving services from a health care provider within your insurance’s network.

Other Insurance Paid:
 If you have coverage with another health plan, this is the amount that the other plan has agreed to pay.

You Are Responsible For: 
Your share of the cost for the services shown on this Explanation of Health Care Benefits (EOB).  You may have already paid this amount to your health care provider.



Provider Information

Great Plains Therapy has contracts with most major insurance companies. 
Some of the most common insurance companies utilized at our clinics are listed below along with the usual benefits for physical therapy offered by those companies.  This list is not inclusive and your individual policy may vary so we recommend that you call our office and request that we check on your individual benefits for you.

Aetna – No prescription is required from your physician.  Plans vary widely as far as how big the deductible is and how many visits are allowed.  We are in-network providers in all of our clinic locations.

Avera –  You must have a prescription from a medical doctor for physical therapy to be covered.   You will have a deductible, a co-insurance, and may have a co-pay with certain plans.  We are in-network providers in Vermillion and Beresford.  We are not in-network providers in our Yankton clinic. Avera will not allow us to be providers as they do not want the competition with Sacred Heart Hospital’s physical therapy program.  Avera offers several different plans.  Call our office and give us your insurance information and we will check on your plan.

Blue Cross Blue Shield of South Dakota – 20 physical therapy visits per plan year are allowed if medically necessary.  You do not need a prescription from your physician to see us.  If you use all 20 visits, BCBS may allow you to have more if they are deemed necessary.  Your individual policy may have a co-pay, deductible, and you may owe co-insurance.  Plans vary widely.  We are an in-network provider for Blue Cross Blue Shield in all of our clinic locations.  BCBC will only pay for a 45 minute treatment session.

Blue Cross Blue Shield of Nebraska – You must have a prescription from a medical physician to receive physical therapy.  You will have a deductible or a co-pay and also will owe a co-insurance amount of usually 20%.  We are in-network providers for Blue Cross Blue Shield in all of our clinic locations.  BCBS will only pay for a 45 minute treatment session. 

Blue Cross Blue Shield of Minnesota – Plans vary widely.  You must have a prescription from a physician.  BCBS will only pay for a 45 minute treatment session.  We are in-network providers in all of our clinic locations. 

Blue Cross Blue Shield of Iowa –  Same as South Dakota.

Cigna – You will need a prescription from your physician.  Plans vary widely as far as how big the deductible is and how many visits are allowed.  We are in-network providers in all of our clinic locations.

Dakotacare (for State of SD employees) – 10 visits are allowed per plan year which runs from July 1 through June 30.  Your therapist may request more visits if necessary.  You must have a prescription from a medical physician for physical therapy.  You will have a deductible of either $300 or $1000, depending on the plan that you chose.  You will have a $15 co-pay if you have a $300 deductible.  If you have the $1000 deductible plan, you will have no co-pay but will have to pay 20% of your allowed charges.  We are in-network providers for Dakotacare in all of our clinics locations.

Dakotacare (for private employers) – 25 visits are allowed per calendar year.  No further visits are authorized for any reason.  You will have a deductible and owe co-insurance.  You may also have a co-pay.  Plans vary.  We are in-network providers for Dakotacare in all of our clinic locations.

First Choice of the Midwest—A Preferred Provider Organization (PPO).  They are not your insurance company and do not pay claims.  Contact your insurance plan administrator for benefit questions as plans vary widely.

Medica—Plans vary widely as far as how big the deductible is and how many visits are allowed.  We are in-network providers in all of our clinic locations.

Medicare –  You do not need a prescription from your physician but a physician must agree to certify your plan of care.   This requires them to read a report that is prepared by your physical therapist, review the treatment recommended and the goals set.  They must sign it if they approve and return it to Great Plains Therapy.  There is a cap on outpatient therapy provided in a private physical therapy clinic but many people have an exception to the cap.  Your therapist has a list of the diagnosis included in the exception and will discuss this with you during your evaluation.  Medicare pays 80% of allowed charges.  You are responsible for the other 20% but many people have a supplemental insurance to cover this.

Medicare and Supplemental -   Your Medicare policy will pay for 80% of your therapy.  Your supplemental, sometimes known as a secondary, will cover the other 20% of allowed charges.

South Dakota Medicaid – We accept Medicaid in our Beresford and Vermillion clinics but not in Yankton.  You will need a prescription from your primary physician to receive physical therapy.  There is no deductible, co-pay or co-insurance owed. 

Sanford -  30 physical therapy visits are allowed per calendar year.  More visits are not typically authorized unless there is a very unusual circumstance.  You do not need a prescription from a doctor for physical therapy.  There is usually a deductible and a co-insurance owed of 20% of allowed charges.   We are in-network providers in all of our clinics for Sanford.

TLC Advantage—A Preferred Provider Organization (PPO). Contact your insurance plan administrator for benefit questions as plans vary widely.

Tricare Prime: 
You need a referral from your primary care manager.  20 visits are allowed per fiscal year.  If you use all 20 visits, Tricare may allow you to have more if they are deemed necessary.  You may have a deductible, co-insurance or co-pay depending on your plan.  We are in-network providers in all of our clinic locations. 

Tricare Standard: 
No prescription is required for the first 20 visits per fiscal year.  If you use all 20 visits, Tricare may allow you to have more if they are deemed necessary and a prescription is needed.  You may have a deductible, co-insurance or co-pay depending on your plan.  We are in-network providers in all of our clinic locations.

Tricare:  For anyone under the age of 21: 
You have unlimited number of visits with a prescription.  You may have a deductible, co-insurance or co-pay depending on your plan. 


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