Out-of-network insurance reimbursement
I do not accept most insurance. This does not mean you can get no help from your insurance in paying my fees: many plans have out-of-network benefits, a process where you can be reimbursed for a portion of my fees.
These reimbursements are subject to the same rules as the rest of your plan. You are still subject to your deductible, co-pays, benefit maximums, and other restrictions.
Provided your insurance does have out-of-network mental health benefits, here is how it works: you pay my full fee, and I give you an invoice, called a superbill, to submit to your provider, who reimburses you according to their own rules and percentages. It is very unlikely your insurance will reimburse 100% of my fee.
I generate superbills at the end of each month, so you will be able to request reimbursement once a month for the preceding month’s sessions.
Call your insurance to confirm benefits
Have your insurance card ready before you call. Below is a script. The reasons for each question follow further down the page.
Hi, my name is ____ and I am calling to check out-of-network mental health benefits for me / my child. I would like to know:
- Do I have out-of-network coverage for outpatient behavioral health or therapy?
- What is the deductible, and how much of it has been met so far?
- Is reimbursement based on the provider’s fee or the plan’s allowed amount (the usual and customary rate)?
- After the deductible, what percentage does the plan reimburse for out-of-network behavioral health services?
- What is the allowed amount for CPT codes 90791, 90834 (for minors), and 90837 (for adults)?
- Do I need prior authorization for out-of-network therapy?
- How do I submit superbills or claims for reimbursement?
- How long does reimbursement typically take?
- Can you please give me a reference number for this call?
Thank you so much for your help.
Why each question matters
This confirms whether reimbursement is possible from your insurance at all.
Your deductible affects how much you are reimbursed. Using my services is no different than using a fully covered therapist. You will have to meet the deductible either way.
Different insurance companies pay different amounts. This clarifies whether they reimburse based on what they would pay an in-network provider, or based on what I charge.
Some insurers reimburse a percentage of the cost, especially for out-of-network care. This finds out whether that applies to your plan.
Every treatment has an insurance code. These are the codes I would use if I billed insurance directly, and the ones you will see on your superbill.
Prior authorization is when an insurer agrees to cover treatment before it happens. Insurers that require it will deny coverage without it, even for treatment they would otherwise cover.
Your insurer may have a patient portal, or you may need to email or fax your superbill.
This helps you plan around when to expect reimbursement.
A reference number lets you refer back to this conversation if you need to talk to your insurer again. It is good practice for any insurance call.