WILLIAM AVERY | PHYSICAL THERAPY INSURANCE VERIFICATION CHECKLIST
https://www.williamaveryco.com/physical-therapy-insurance-verification-services
Reviewed October 3, 2026

Use within your practice's approved secure workflow. Record the source and
limitations of each answer. An eligibility response does not guarantee payment.
This blank worksheet is a planning tool, not a completed benefit verification.

1. REQUEST CONTEXT
Internal record reference:
Planned service date(s):
Services and setting to verify:
Member/subscriber information checked against current registration:
Plan name and identifier:
Rendering provider, billing entity, and service location:
Requested by / date needed:

2. COVERAGE AND BENEFITS
Effective dates for the planned visit:
Relevant provider/location network status and source:
PT benefit and applicable exclusions:
Deductible information and date reported:
Copay / coinsurance information:
Out-of-pocket information where relevant:
Other coverage or coordination questions:
Information unavailable or requiring clarification:

3. VISITS, UNITS, AND APPROVALS
Benefit period / reset date:
Any visit or unit limit and whether disciplines share it:
Use reported by payer / practice and date of each report:
Unprocessed visits that may not appear in reported use:
Referral requirement and available record:
Authorization requirement and source:
Approval identifier, status, and applicable provider/location:
Approved services, dates, visits or units:
Remaining allowance and basis for calculation:
Owner of any request, extension, or clinical-record follow-up:

4. RESPONSE EVIDENCE
Payer portal / response / representative:
Date and time of check:
Response or call reference:
Location of the response in the approved system:
Conflicting answers and how they will be resolved:

5. HANDOFF
Confirmed information:
Unresolved questions:
Next action / owner / due date:
Practice contact informed / date:
Patient estimate questions for the practice to address:
Next recheck date or trigger:

Do not mark an entire review complete while a material question is unresolved.
A benefit check, an authorization request, and an authorization approval are
separate statuses. Confirm task ownership in your service agreement.

Sources:
CMS Eligibility Inquiry
https://www.cms.gov/medicare/coding-billing/electronic-billing/eligibility-inquiry
CMS HETS Companion Guide
https://www.cms.gov/files/document/current-hets-270/271-companion-guide.pdf