Out-of-Network Physical Therapy and Superbills Explained

Out-of-network physical therapy means seeing a physical therapist (PT) who has no contract with the patient's health plan. In the setup this guide covers, the patient pays the clinic directly, and the clinic hands over a superbill: an itemized statement of the visit, with the codes and provider details a plan needs, which the patient sends in to ask for money back. Whether the plan pays anything, and how much, is decided by the patient's plan, not by the superbill.

It is written for US PTs and clinic owners who are out of network with one or more insurers, and for patients weighing up a visit to one. It covers commercial insurance, the good faith estimate the No Surprises Act requires for uninsured and self-pay patients, and why Original Medicare works differently.

Federal rules and CMS pages are quoted as they read on September 28, 2026. The reference list gives the date of every source. Treat all of it as education, not billing or legal advice. Plan terms change, and so do state rules and federal guidance. Check the current versions, and talk to a healthcare attorney or billing specialist before you change how your clinic bills.

What in-network and out-of-network mean

The HealthCare.gov glossary defines a network as "The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services." An in-network, or preferred, provider is "A provider who has a contract with your health insurer or plan to provide services to you at a discount." A non-preferred provider is "A provider who doesn't have a contract with your health insurer or plan to provide services to you," and the glossary adds: "You'll pay more to see a non-preferred provider."

So the whole difference is the contract. An in-network PT has signed up to the plan's rates and rules, bills the plan and collects the patient's share. Out of network, there is no agreement and the clinic sets its own fee. If the plan covers out-of-network care at all, it decides for itself what it will pay toward that fee. A PT can be in network with one insurer and out of network with the next, because each contract is separate.

Three more glossary terms explain why the money a patient gets back is often less than the fee they paid:

Allowed amount: "The maximum amount a plan will pay for a covered health care service." The glossary warns that "If your provider charges more than the plan's allowed amount, you may have to pay the difference."
Out-of-network coinsurance: "The percentage (for example, 40%) you pay of the allowed amount for covered health care services to providers who don't contract with your health insurance or plan."
Balance billing: when a provider bills the patient for the gap between their charge and the allowed amount. The glossary notes that "A preferred provider may not balance bill you for covered services." An out-of-network PT has made no such promise to the plan.

Does insurance cover out-of-network physical therapy?

It depends first on the type of plan. HealthCare.gov describes the common types like this:

EPO: a managed care plan where "services are covered only if you use doctors, specialists, or hospitals in the plan's network (except in an emergency)."
HMO: "It generally won't cover out-of-network care except in an emergency."
POS: a plan where "you pay less if you use doctors, hospitals, and other health care providers that belong to the plan's network." The same page says POS plans need a referral from the primary care doctor to see a specialist.
PPO: "You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost."

These are general descriptions, and the patient's own plan documents are what count. Still, say the pattern out loud at booking. A patient on an HMO or EPO plan may get nothing back for an out-of-network PT, however good the superbill is.

The deductible matters too. HealthCare.gov defines it as "The amount you pay for covered health care services before your insurance plan starts to pay." Until the patient has met the deductible that applies to out-of-network care, they may send in superbills and get nothing back yet, even on a plan that covers it. Warn them. They can ask the plan whether those claims still count toward the deductible.

What is a superbill?

A superbill is an itemized statement of the care you gave and what the patient paid, set out so the patient can file their own claim with their plan. The word comes from everyday practice. None of the federal sources in this guide defines it, and no single format is required. Each plan decides what it accepts, so the patient should look at the plan's member claim form, or ask member services, before sending anything.

What to put on a physical therapy superbill

The simplest approach is to include the details a professional claim needs. Chapter 26 of the Medicare Claims Processing Manual goes through Form CMS-1500, the claim form for professional services, item by item. Those items work as a checklist even when the payer is not Medicare:

Diagnosis codes. Item 21 asks for "the patient's diagnosis/condition." CMS says "ICD-10 applies to all parties covered by the Health Insurance Portability and Accountability Act (HIPAA)," so these are ICD-10-CM codes.
Date of each service. Item 24A asks for a date "for each procedure, service, or supply."
Procedure codes. Item 24D uses HCPCS codes. CMS explains that Level I of HCPCS is the Current Procedural Terminology (CPT) code set maintained by the American Medical Association, 5-digit codes used primarily to identify services from physicians and other health care professionals. Item 24G asks for "the number of days or units." Count units for timed codes the way the patient's plan counts them; how the 8-minute rule counts timed minutes sets out where payers differ.
The charge for each line. Item 24F: "Enter the charge for each listed service."
The rendering PT's NPI. Item 24J asks for the rendering provider's NPI. CMS describes the National Provider Identifier as "a unique identification number for covered health care providers," a 10-digit number.
The federal tax ID. Item 25 asks for the "Federal Tax ID (Employer Identification Number or Social Security Number)."
Who billed and where care took place. Item 33 holds the billing provider's name, address with ZIP code, and phone number. Item 32 is the location where the services were furnished.
A signature and date. Item 31.

It also helps to add the patient's name, date of birth and plan member ID, plus the amount paid, the date it was paid and a line showing the balance is zero. That is suggested practice, not a rule. It saves the patient from having to explain to the plan that the bill is already settled. Sole proprietors should think about whether the clinic's EIN can go on the form in place of their Social Security Number, since the patient will post or upload this paper.

Only put codes on a superbill that match what you did and what your notes support. The superbill ends up with an insurer, so give it the care you would give a claim you file yourself. For the records behind it, the physical therapy plan of care covers what a plan should hold, and SOAP notes covers visit notes.

How patients get reimbursed with a superbill

Order matters here. Ask the plan first, then book.

Call the plan, using the member services number on the insurance card, before the first visit.
Pay the clinic as agreed and collect a superbill, per visit or for a set period, as the clinic offers.
Send it in with the plan's claim form, by the method the plan accepts. Keep copies of everything you send.
Read the plan's decision when it arrives. If a claim is denied, ask the plan for the reason and whether you can appeal.

Questions worth asking the plan on that first call:

Does my plan cover outpatient physical therapy from an out-of-network provider?
Is there a separate out-of-network deductible, and how much of it have I met so far this year?
What is my out-of-network coinsurance, and how does the plan work out its allowed amount?
Is there a limit on physical therapy visits per year, and do out-of-network visits count toward it?
Do I need a referral, a prescription or prior authorization before the first visit?
How do I submit a claim, what must be on it, and is there a deadline?

The answer to the referral question can differ from what your state allows a PT to do. Direct access to physical therapy explains that split between state law and plan rules.

Do out-of-network PTs have to give a good faith estimate?

The No Surprises Act is, in CMS's words, "a federal law that went into effect on January 1, 2022." Its consumer page for people not using insurance says: "Usually, if you don't have or use health insurance to pay for your care, providers must give you a good faith estimate of how much it will cost." In a cash-pay or out-of-network PT practice, this is the part of the Act you will meet most often.

The rule is 45 CFR 149.610. It defines a "health care provider" as "a physician or other health care provider who is acting within the scope of practice of that provider's license or certification under applicable State law." CMS's provider FAQs add that a provider who never works in connection with a visit to a health care facility would still "need to provide a good faith estimate of expected charges to uninsured or self-pay individuals, when applicable." An uninsured (or self-pay) individual includes someone with no coverage for the service, and also someone who has coverage "but who does not seek to have a claim for such item or service submitted to such plan or coverage." To find out who counts as uninsured or self-pay, the provider must ask whether the person has coverage and, if so, whether the person "is seeking to have a claim submitted for the primary item or service with such plan or coverage."

The regulation says nothing about superbills. A patient who pays you directly and later sends their own claim to the plan sits awkwardly in that definition, and none of the CMS pages opened for this guide settles which side they fall on. The cautious route, offered as suggested practice rather than legal advice: ask every patient the required question, write down the answer, and give a good faith estimate to anyone who will pay you directly. It costs little, and if the patient does count as self-pay, you have already met the rule. Insured patients who want a claim sent to their plan fall under separate provisions that this guide does not cover.

When the estimate is due

Under paragraph (b)(1) of the rule, the estimate must be provided:

when the service is scheduled at least 3 business days ahead: "Not later than 1 business day after the date of scheduling"
when it is scheduled at least 10 business days ahead: "Not later than 3 business days after the date of scheduling"
when the patient asks for one: "Not later than 3 business days after the date of the request"

It must be in writing: "A good faith estimate must be provided in written form either on paper or electronically, pursuant to the uninsured (or self-pay) individual's requested method of delivery." The rule also says information about the availability of good faith estimates must be "prominently displayed (and easily searchable from a public search engine)" on the provider's website, "in the office, and on-site where scheduling or questions about the cost of items or services occur," and given orally when a service is scheduled or when cost questions come up. Watch the cost questions in particular. The rule says providers "shall consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate." A patient who asks what a course of therapy will cost has, in effect, asked for an estimate, and the 3 business day clock starts.

What the estimate must contain

Paragraph (c)(1) sets the contents. In plain terms:

the patient's name and birth date
a plain description of the main service
the expected items and services, itemized and grouped by provider
the diagnosis codes, expected service codes and expected charges that apply
each provider's name and NPI, plus its Tax Identification Number

The paragraph also lists several disclaimers. One says the estimate "is not a contract", and another tells the patient about the dispute process. Work from the paragraph itself when you build your template.

Estimates for a course of physical therapy

Physical therapy is rarely one visit, and the rule allows for that. A provider "may issue a single good faith estimate for recurring primary items or services" if the estimate sets out "the expected scope of the recurring primary items or services (such as timeframes, frequency, and total number of recurring items or services)." The rule adds that "The scope of a good faith estimate for recurring primary items or services must not exceed 12 months." Care expected to run longer than that needs a new estimate. Your plan of care already states the expected visit frequency and duration, so build the scope from that.

A new estimate can be due well before the 12 months are up. When you expect the scope of an estimate already given at scheduling to change (the number of visits, say, or the charges), the rule requires a new one "no later than 1 business day before the items or services are scheduled to be furnished." Each time you revise the plan of care, check whether the estimate has to be reissued as well.

Records and disputes

Providers must give a copy of "any previously issued good faith estimate furnished within the last 6 years" when the patient asks for it. On the patient side, CMS says: "You can dispute a bill if one of your providers or facilities charged at least $400 more than their estimate." It adds that the dispute must start "within 120 days (about 4 months) of getting your initial bill." CMS also tells patients they need the estimate in writing to use the No Surprises Act dispute process. Keep your copies in order.

Medicare patients: why a superbill is not the answer

Original Medicare has its own rules, and habits from commercial out-of-network billing do not carry over. The Medicare Benefit Policy Manual, Chapter 15, section 40, opens with the basic duty: "Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B." The same section warns that a physician, practitioner or other supplier who fails to submit a claim for a covered Part B service within 1 year of providing it may face civil monetary penalties. The one case section 40 names where a claim is not required is a beneficiary who, of their own free will, refuses to authorize the submission of a bill to Medicare, and the charge limits still apply then.

Some professionals can step outside this by opting out of Medicare and signing private contracts with patients. Physical therapists cannot. Section 40.4 of the manual says: "Physical therapists in independent practice and occupational therapists in independent practice cannot opt out because they are not within the opt out law's definition of either a 'physician' or 'practitioner'."

APTA spells out what that means for cash practices. Its guidance on cash-based payment and Medicare states: "Any PT who furnishes Medicare covered services and privately bills and collects payment directly from a beneficiary is in violation of the law." It adds that "Nothing in the rules allows for a non-enrolled PT to provide Medicare-covered services to a beneficiary simply because the patient prefers seeing the non-enrolled PT rather than a PT who is enrolled in the Medicare program." APTA also says the "patient-refusal" exception is available only to enrolled providers. In short, a PT who is not enrolled cannot see an Original Medicare patient for covered services on a cash basis and give them a superbill to send in.

What if the patient needs covered and noncovered services? The same APTA page says the PT must then be enrolled and file claims for the covered services. Only the noncovered services can be billed directly to the patient. For an enrolled PT, before a service that Medicare usually covers but may not cover in a particular case, section 40 describes giving an Advance Beneficiary Notice of Noncoverage (ABN), and the KX modifier guide explains when an ABN applies in therapy.

Medicare Advantage plans are outside the scope of this guide, and so are Medicaid and other government programs. Check with the plan or program, and with a billing specialist, before treating one of those patients out of network or for cash.

This may change: on July 1, 2025, APTA reported that the Medicare Patient Choice Act (H.R. 4204) had been introduced in Congress with its support, to add PTs to the list of providers who may opt out. Congress.gov shows it was introduced in the House on June 26, 2025. On September 28, 2026 the site listed the bill's status as introduced, with referral to committee as the latest action, and the manual section quoted above still said PTs cannot opt out. Check the current position before you rely on either.

Talking to patients about out-of-network care

The points below are suggested practice, drawn from the rules above rather than from any single source. The idea is that a patient never hears about a cost for the first time on a bill.

Ask two questions when the patient books: which insurance do you have, and do you want to use it? Record the answers. If the answer to the first is Medicare, handle the booking under the Medicare rules above.
Say you are out of network before the first visit, not on the first bill.
Give a short written financial policy with your fee for each visit type, when payment is due, that you provide superbills, and that any reimbursement is between the patient and their plan. Put your cancellation policy in the same document.
Hand over the good faith estimate in writing, and keep a copy.
Give the patient the list of questions for their plan. Never quote a reimbursement figure you have not seen in writing from the plan.

A sample script for the front desk: "We're out of network with your plan. You pay us at each visit, and we give you a superbill to send to your plan. What your plan pays back depends on your plan, so it's worth calling them first. Here are the questions to ask."

A patient who pays per visit relies on the home program between appointments, so write it clearly. For the clinical side, see how to write a home exercise program. PocketPhysio pairs each exercise with its own video and voice guide. Once the program is ready in the app, it goes out by link, SMS or email; patients on Pocket Physio Care, the patient app, receive it there, and WhatsApp is one more option. For clinic management, appointments and billing there is VirtueLife, the complete platform for physiotherapy clinics from the makers of PocketPhysio.

Common mistakes with out-of-network billing and superbills

Telling a patient their insurance "should cover most of it". You cannot know that. Only the plan can.
Codes on the superbill that your notes do not support.
A superbill without the diagnosis codes, the NPI or the tax ID the plan needs to process it.
No good faith estimate for a patient paying directly, or one given only after the first visit.
A single estimate for a course of care that gives no timeframe, frequency or total number of visits, or that runs past 12 months.
Treating an Original Medicare patient for covered services as a cash patient with a superbill.
Assuming every plan covers out-of-network care. EPO and HMO plans generally do not, outside an emergency.
No notice on your website or at the front desk that good faith estimates are available.

The short version

Out-of-network physical therapy means the PT has no contract with the patient's plan. In the setup covered here, the patient pays the clinic and files a superbill. The plan then decides what, if anything, it allows and pays back. Build the superbill from the details of a professional claim (diagnosis and CPT codes with dates of service and charges, plus the NPI and tax ID) and expect plans to differ in what they accept.

Uninsured and self-pay patients are owed a written good faith estimate on the timetable the No Surprises Act sets. One estimate for a course of care cannot run past 12 months. Original Medicare works differently. PTs cannot opt out, so a PT who is not enrolled cannot treat a Medicare patient for covered services for cash and give them a superbill instead.

References

HealthCare.gov. Glossary: Network; Preferred provider; Non-preferred provider; Allowed amount; Out-of-network coinsurance; Balance billing; Deductible. Accessed September 28, 2026. https://www.healthcare.gov/glossary/
HealthCare.gov. Health insurance plan & network types: HMOs, PPOs, and more. Accessed September 28, 2026. https://www.healthcare.gov/choose-a-plan/plan-types/
Centers for Medicare and Medicaid Services. Know your medical bill rights when not using insurance. Page last modified August 25, 2026. Accessed September 28, 2026. https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/know-your-medical-bill-rights/know-your-medical-bill-rights-when-not-using-insurance
Code of Federal Regulations. 45 CFR 149.610, Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals, paragraphs (a)(2), (b)(1), (c)(1), (e)(1), (f)(1) and (g)(1). Legal Information Institute, Cornell Law School. Accessed September 28, 2026. https://www.law.cornell.edu/cfr/text/45/149.610
Centers for Medicare and Medicaid Services. Frequently Asked Questions for Providers About the No Surprises Rules. April 6, 2022. Accessed September 28, 2026. https://www.cms.gov/files/document/faq-providers-no-surprises-rules-april-2022.pdf
Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual (Publication 100-04), Chapter 26: Completing and Processing Form CMS-1500 Data Set (Revision 12779, issued August 9, 2024). Items 21, 24A, 24D, 24F, 24G, 24J, 25, 31, 32 and 33. Accessed September 28, 2026. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf
Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System (HCPCS). Page last modified August 12, 2026. Accessed September 28, 2026. https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system
Centers for Medicare and Medicaid Services. ICD-10. Accessed September 28, 2026. https://www.cms.gov/medicare/coding-billing/icd-10-codes
Centers for Medicare and Medicaid Services. National Provider Identifier Standard (NPI). Page last modified August 14, 2026. Accessed September 28, 2026. https://www.cms.gov/regulations-and-guidance/administrative-simplification/nationalprovidentstand
Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual (Publication 100-02), Chapter 15: Covered Medical and Other Health Services (table of contents Revision 13889, issued July 30, 2026). Section 40, Effect of Beneficiary Agreements Not to Use Medicare Coverage; section 40.1, Private Contracts Between Beneficiaries and Physicians/Practitioners; section 40.4, Definition of Physician/Practitioner (Revision 62, effective November 13, 2006). Accessed September 28, 2026. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
American Physical Therapy Association. Cash-Based Payment and Medicare Services: No Exceptions to the Rules. No date shown. Accessed September 28, 2026. https://www.apta.org/your-practice/payment/cash-practice/cash-based-practice-medicare
American Physical Therapy Association. APTA-endorsed Legislation Allowing Physical Therapists to Opt Out Under Medicare Introduced in Congress. July 1, 2025. Accessed September 28, 2026. https://www.apta.org/article/2025/07/01/apta-endorsed-legislation-allowing-physical-therapists-opt-out-under-medicare-introduced-congress
Congress.gov. H.R.4204, Medicare Patient Choice Act, 119th Congress (2025-2026): all actions. Accessed September 28, 2026. https://www.congress.gov/bill/119th-congress/house-bill/4204/all-actions

Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.

Out-of-network physical therapy and superbills: a guide for PTs and patients