Navigating the insurance world can be complicated. You’ve found a therapist who feels like a good fit, but they don’t accept your insurance. What do you do next?
First, lets break down some key terms
In-network provider: a therapist who is paneled with your insurance company and bills the insurance company directly. When you work with an in-network provider, you pay a co-pay to the therapist, and they take care of the rest.
Out-of-network (OON) provider: a therapist who is not paneled with your insurance company and cannot submit claims on your behalf. When working with an OON provider, you will pay the therapist and then submit the claim yourself to your insurance company for any potential reimbursement. If eligible, the insurance company will send a check for reimbursement directly to you.
Out-of-network deductible: Most plans have an out-of-network deductible. This means that you would have to pay the specified deductible amount before insurance would agree to cover a percentage of the session cost. OON deductibles range from $250 to thousands of dollars depending on your plan.
Superbill: A superbill is a summary of the services provided to the client which they submit directly to the insurance company. Insurance companies will not accept standard invoices as proof of service. The superbill contains all the providers necessary information (license number, NPI, Tax ID) and the information regarding your service (session type, length of session, location of session, and diagnosis).
How to Determine If You Have Reimbursement Potential
Check Your Insurance Card
Some insurance cards have this information printed right on the front of the card. If so, it will state both the in-network and the out-of-network deductible costs. If your card does not have any OON information printed on it, you will have to check your client portal with the insurance company, or call them directly.
Call Your Insurance Company
To check coverage over the phone, call the customer service number on the back of your insurance card. You will listen to the prompts and select the option to review benefits and eligibility. Once connected to a customer service representative, you will ask them the following questions:
- – Do I have out-of-network coverage
for outpatient mental health services (CPT code: 90834) with a licensed mental health counselor? - – Is there an out-of-network deductible?
- – What percentage will I be reimbursed?
- – Is there a pre-authorization required?
- – How do I go about submitting a claim?
It is helpful to record the name of the representative and ask for a reference number for the phone call.
Important Points to Note
When using your insurance, with in-network or out-of-network, your therapist is required to provide the company with a mental health diagnosis. This diagnosis becomes a part of your permanent medical record with the company. Additionally, when using insurance to cover sessions, they can request progress notes, treatment plans, or other documentation about your progress. They can deny payment if they do not feel therapy is medically necessary.