You may not want to use your insurance benefits when paying for therapy due to confidentiality and privacy concerns; instead, you prefer to pay out of pocket for services.
However, if you would like to use your insurance benefits to see an out-of-network provider, here are some tips.
You can check online. Look for your “Summary of Benefits” on your insurance provider’s website. While reading through your plan summary, look for phrases like “out-of-network deductible” and “coinsurance” or “copayment.” Your out-of-network deductible is how much you have to pay before you can access your out-of-network benefits and be reimbursed. For example, you may have an out-of-network deductible of $500. Once you pay that amount, your insurance company will cover 100% of out-of-network service fees. You’ll have met your deductible after you pay $500 and will be eligible for reimbursement. This means that if you spend $1,000, you’ll be responsible for $500 of that and then your insurance company will reimburse you for all or a portion of the remaining $500. This normally comes to you in the form of a check and is mailed directly to you after you submit a claim. Your deductible will most likely reset at the beginning of each calendar year.
“Co-insurance” is the portion of the service fee that you will have to cover. If the session fee is $200 and your co-insurance is 50%, you are responsible for $100 and your insurance will reimburse you the other $100. Your co-insurance will not kick in until you reach your deductible. If your insurance company has an “allowed” amount, this means there’s a max that they will pay out to reimburse you. For example, if the “allowed” amount is $100 for each session, your co-insurance is 50%, and the session fee is $200, then the reimbursed amount will cover a maximum of $100.
Call your insurance company. Locate the phone number on the back of your insurance card for “Member Services” which may also be listed as “Customer Service.” If there is a separate number for “Behavioral Health,” this is the number you will need to call. Listen carefully to the options and choose the option that best fits “check benefits” for “outpatient behavioral health” or “mental health” office visits.
Sometimes mental health benefits are contracted out to another company, so your insurance company may give you another number to call or transfer you straight to that company. Once you connect with the right company and department, you may follow this script to verify out-of-network benefits after you reach a live representative on the phone:
Do I have out-of-network coverage for mental health/behavioral health services provided through telehealth? (If the answer is “no,” then you will not be eligible for any reimbursement when you see an out-of-network provider). If yes, proceed.
What is my annual deductible? How much of the annual deductible has been met this year?
How many sessions per year does my plan cover?
How much does my insurance plan reimburse for an out-of-network provider for CPT code 90837?
What is my copayment or co-insurance (if applicable)?
Do I need a referral from my primary care physician?
What is the home and mailing address you have on file? (It’s important to ensure checks are issued to the correct address.)
How do I submit a superbill? Is there an online portal or fax number, or do I need to mail in a copy?
What is the time limit to submit a “superbill”?