Understanding Visit Limits in Pediatric Therapy


  • What does understanding visit limit mean in Pediatric Therapy mean?
  • What is the difference between hard and soft visit limit?
  • If my visit limit says 60 visits, why does my insurance not let me use all those visits?
  • What does “Medically Necessity” mean? If I have 60 visits why is insurance saying it’s not medically necessary?

Visit Limit

is a set number of visits your plan will consider for services for the year. For Pediatric Therapy, this may be a combined visit limit for any/all services. It could also be a separate limit for Physical, Occupational, and Speech Therapies. 

Hard Limit

is when your insurance company determines a set number of visits per year, such as 30. They will not pay for any therapy services once you have reached that number. As a result, if you choose to continue to treat after your hard max, those services would be your full responsibility, and will not be applied to your insurance deductible, co-insurance, or out-of-pocket expense. 

Soft Limit

is when your insurance company says they are allotting a set number of visits, such as 30, BUT they will consider additional visits beyond that number based on their determination of medical necessity. They would review medical records, and determine if therapy services are warranted, and could choose to allow or deny additional visits based on their review. And note, extra visits are not a guarantee.

My plan says I have 60 visits, and I was cut-off at 40. Why? 

Some insurance plans will say your plan has a set number of visits, but that does not necessarily mean you can “use” all of them. Many times, insurance companies request medical records from your Pediatric Therapy provider, and perform their own independent medical review. They can determine at any time, services are no longer needed. If that occurs, you would be financially responsible for those services.

What does Medical Necessity mean?

Many insurance companies have outside review companies they partner with to review records. They determine if they “feel” services are warranted, or a patient can be discharged from care. In short, f the reviewer determines that visits are not medically necessary based on their criteria, they will no longer cover services. 

Written by Ann Marie Johnson

Understanding Your Explanation of Benefits (EOB) for Pediatric Therapy

Understanding your Explanation of Benefits: Understanding your Explanation of Benefits (EOB) for Children’s Speech, Occupational or Physical Therapy is important to ensure that your insurance is working. And above all, to eliminate surprises that result in unexpected expenses.

Keeping track of denials: Many times the insured (you)  gets the EOB in the mail before the provider (BDI). Therefore, if you see something that doesn’t look right, you can call your insurance or your pediatric therapy billing office right away, before you accumulate a large bill you might not be prepared for.

  • Look for accuracy: It is in your best interest to watch your EOBs from your insurance to verify services are accurate. Noticing an error can be brought to your provider’s attention sooner so it can be corrected immediately.    
  • Reading an explanation of benefits (EOB) from your insurance for your child’s pediatric therapy can be a little confusing at times. Some pediatric therapies use the same or similar codes for treatment. These are called CPT codes. A CPT code is the code assigned to the therapy to describe the type of therapy your child had.
  • The office will bill a set rate (or charge) to your insurance for those CPT codes. If our company has a contract with your insurance; a discount might be offered and included on your EOB. Based on your benefits, you would be responsible for any unmet deductible, coinsurance, or copay

1-What services were performed.

2-The amount that was billed to your insurance.

3-Your insurance allowed this amount for that service, based on our contract with them, if any.

4-The amount your insurance paid the company based on your policy benefits.

5-Name of the organization that was paid for the service (BDI, or Bautz Developmental Intervention)

6-What your financial responsibility is for this date of service based on your policy benefits. (This would be deductible, copay or coinsurance portion.)

7-The reason for any non-payment or adjustment (reduction in payment) that was made. 

Our goal is to make funding for your insurance as stress-free as possible. If you need additional help, we are only a phone call or email away! Our patient families can reach us at office@bdiplayhouse.com or 708-478-1820.

Written by:

Ann Marie Johnson

BDI Playhouse Insurance Billing Specialist and Assistant Office Manager

Woman trying to understand EOB

The Difference Between Co-pay, Co-insurance, Deductible and Out-of-Pocket

Understanding the difference between co-pay, co-insurance, deductible and out-of-pocket costs on an Explanation of Benefits (EOB) for Pediatric Therapy can be confusing. Your insurance should provide guidance, but this may help you sort it out.

It’s likely that you have questions such as:

  1. What is a co-pay?
  2. What is the difference in co-pay and co-insurance?
  3. Who do I have to pay for my deductible?
  4. Will, I ever not have to pay co-insurance?
  5. What is the difference between in and out of the network?

A Co-payment (co-pay)

Co-payment is a fixed amount your insurance determines to be your portion to pay per visit. This payment can also be different based on what type of visit you are having. Such as office visits, specialist visits, ER visits, etc.  Pediatric Therapy is considered a specialist visit. Co-pay usually does not apply to a deductible. 


Co-insurance is the percentage your insurance has agreed is your financial obligation to pay. Your insurance plan will pay a percentage of covered expenses, and you would pay the remaining percentage. This amount can vary depending on whether or not your provider is in or out of network with your plan. Your insurance company will start applying charges to your co-insurance once your deductible is met.

Your Deductible

Your deductible is the portion of your medical expense that you would be financially responsible to pay PRIOR to your insurance paying their portion of your co-insurance. Deductibles typically start over at the beginning of the year, but that can vary from plan to plan. Pediatric Therapy claims applied to your deductible are your full responsibility. Your deductible amount may be different based on whether your provider is in-network or out of network with your plan. If a covered claim is applied to your deductible, you would pay the provider for the amount your insurance deems is your responsibility.

An Out-of-Pocket maximum

Out-of-pocket maximum is a pre-determined amount your insurance company deems to be the most you have to pay per year for medical expenses. When you reach this amount, your insurance will begin to start paying your allowed medical expenses at 100% for the remaining portion of the benefit year. 

In and out of Network:

Your insurance may provide a smaller deductible and smaller co-insurance portion if you choose to see a provider the insurance company has a contract with. This can be large cost savings for you. For example, if you were to have Pediatric Therapy with an in-network clinic, you may have a $500 deductible, with 90% co-insurance (you owe 10%) and a $2500 out-of-pocket max.  If that treatment is provided at a clinic that is NOT contracted with your insurance, you may see that your deductible is now $1500, and your co-insurance is now 70% (you are responsible for 30%) with a $5000 out-of-pocket max. 

Understanding your insurance benefits can be an overwhelming task. Above all, one of the most important things to know when you make appointments for services, such as Pediatric Therapy, is to ask your insurance company if the clinic is in or out of network with your plan, as you may have a much larger portion that is your responsibility to pay if they are out of network than you had thought. 

BDI Playhouse offers support with understanding your pediatric therapy benefits. Our knowledgeable office team provides information and guidance to streamline and support processes to save your precious family time.

Written by:

Ann Marie Johnson

BDI Playhouse Insurance Billing Specialist and Assistant Office Manager

Insurance & Billing For Current Clients

Insurance and Billing Information

Providing the best services for your child requires a HIGHLY TRAINED TEAM of therapists AND office professionals.

Our knowledgeable office team provides information and guidance to streamline and support processes that save your precious family-time. Securing coverage or providing a plan that allows your child to receive uninterrupted QUALITY services is our goal.

If you have questions, we have answers. Call us any time or schedule a call with our office at a time that is convenient for you HERE.

100+ years of combined office and billing experience

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Insurance & Billing For New Clients

Insurance & Billing For New Clients

For general information related to coverage guidelines that commonly apply, please select your insurance below:

  • Blue Cross Blue Shield

    • BDI Playhouse is in-network with BCBS PPO plans. 
    • BDI is not in-network with BCBS HMO plans.
    • Most plans have generous Pediatric Therapy benefits.
    • Some plans limit coverage so please check with your carrier for any limitations on your policy.
  • Aetna

    • Most Aetna plans only cover speech therapy when it directly relates to a birth defect, brain injury, stroke, or head trauma.  Review Aetna’s policy regarding Speech-Therapy coverage for more information.
    • Aetna does not cover the cost of Aquatic therapy.  BDI offers a Private Pay rate if services are not covered. 
    • Aetna allows one appointment maximum per day.  
    • While your plan may have an annual visit allowance, that is not considered a guarantee of coverage. Coverage of services is always dependent on medical necessity, not the policy’s annual visit limit.



  • United Healthcare

    • BDI Playhouse is not in-network with United Health Care Plans. 
      • Therapy can be billed to UHC and will process to your Out of Network benefits
      • Specific billing codes can be provided to help you confirm coverage.
  • Private Pay Discount Details

    In the event that insurance funding is not available, or services are limited or not covered by the policy, our private pay discount rate offers parents another option. Details on the discount for our affordable private pay rate options can be found here.


  • Early Intervention Funding

    Early Intervention (EI) is a state-funded program offering services to children birth to age three with a qualifying level of delay or qualifying diagnosis. 

    • EI serves as a secondary insurance: Providers bill your insurance first and then Early Intervention for portions not covered by your plan.
    • A monthly family fee typically applies
    • Services are often required (by the program) to be provided in the family’s home and children with this funding source are rarely approved for services in-clinic at BDI. 

    Many families receive services BOTH through the Early Intervention AND separately through their insurance so that they may receive services in clinic, allowing the best of both worlds in their child’s intervention. 

    Waiting periods in Early Intervention are common. We recommend scheduling a free screening or consultation at BDI Playhouse prior to starting the Early Intervention evaluation process, as we can typically schedule within one week.  We can also offer services temporarily while you wait for Early Intervention to complete the initial evaluations, schedule a meeting to generate the service document called an IFSP, and assign treating therapists. 

    More detailed information regarding this program can be found here.

    Please review the Early Intervention website, but do not hesitate to ask us to walk you through how the Early Intervention Program works and how accessing this resource might benefit your family. 

  • Cigna

    Starting January 1, 2023, BDI Playhouse will not be in-network with Cigna PPO plans. 

    • Therapy can be billed to Cigna and will process to your Out of Network benefits
    • Specific billing codes can be provided to help you confirm coverage.
  • Other Insurance Plans

  • Multiplan Network participant: offers a 10% discount for Out of Network claims


Claims billed to any other insurance plan would process to your Out of Network benefits coverage.

  • HMO Plans

    • We are contracted BCBS Ingalls HMO. 
    • For other HMOs ask your child’s pediatrician to provide assistance in requesting a “single case agreement or waiver” to allow for coverage outside the network, at your in-network level of benefits. Click here for instructions to begin that process.  
    • If coverage cannot be secured, please consider our private pay discount rates. 
  • Medicaid and State Plans

    • BDI is not contracted with Government supported plans such as Medicaid or any State-funded plans (Illinois Medicaid, BCBS Community, Illinicare, Meridian, Health Alliance, Aetna Better Health, County Care, etc).
    •  We offer a significantly discounted private pay rate. Please see the attached link for more information.


  • DSCC

    • DSCC: is the Division of Specialized Care for Children
    • Financially assists IL families and Children with special healthcare needs
    • Acts as a secondary insurance and often covers what primary insurance doesn’t
    • Eligibility is determined by family income and  the diagnosis or needs of the child


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