My services may be covered in part or in full by your insurance company. However, I am not an in-network provider. Please check your coverage by asking your insurance company the following questions:
- Am I eligible for outpatient psychotherapy?
- Can I use an out-of-network provider?
- What is the out-of-network deductible?
- When does the yearly out-of-network deductible begin? (January 1st, or another date)
- How much of the out-of-network deductible has been met?
- What is the percentage rate for reimbursement?
- Is there a limit to the number of sessions?
- Do they require pre-certification for treatment?
A Step-by-Step Guide to Out-of-Network Benefits
1. Check your out-of-network benefits
These are typically in the Summary of Benefits, included in a member information packet or on your insurance company website. Keep an eye out for these terms:
- Out-of-network deductible: This is the amount of money you have to pay before you are eligible for reimbursement.
Let’s say your out-of-network deductible is $1,000, and your insurance company pays for 100% of services after you meet that amount. That means you’ll have to pay $1,000 out of pocket, after which you’ll have “met your deductible.”
In this scenario, if you spend $1,500 on therapy services, you’ll have to pay $1,000 out of pocket (e.g. $100 at each session for 10 sessions), but the remaining $500 will be reimbursed to you in the form of a check (mailed to you after you submit your claim).
Deductibles reset every calendar year, and any health expense you pay out-of-pocket contributes to meeting it.
- Coinsurance: This is the percentage of the service fee that you’re ultimately responsible for paying.
For example, if the fee is per session is $175 and if your coinsurance is 25%, you’re only responsible for paying $43.75. (Note: You’ll need meet the deductible first and submitted a claim in order to receive reimbursement.)
Some insurance companies determine an “allowed amount,” which caps the session fee that they’ll cover. If your insurance has determined $100 is their “allowed amount” per session, at a 25% coinsurance rate, your insurance company will still only reimburse you up to $75, no matter what the therapist’s session fees are.
In other words, if your insurance has an allowed amount of $100 but the session fees are $175 per session, you won’t get reimbursed more; you’ll still be reimbursed $75, and will be ultimately responsible for $125.
2. Call your insurance company to verify your benefits
The best way to be absolutely sure of your benefits is to clarify with your insurance company member services line. You can find this phone number on the back of your insurance card.
Ask these questions when speaking to your insurance company about benefits:
- How much of my deductible has been met this year?
- What is my out-of-network deductible for outpatient mental health? (Outpatient means treatment outside a hospital.)
- What is my out-of-network coinsurance for outpatient mental health?
- Do I need a referral from an in-network provider to see someone out-of-network?
- How do I submit claim forms for reimbursement? (Claims are forms that are sent to your insurance company to receive reimbursement for sessions you paid for out of pocket.)
3. Submit your Superbill for out-of-network reimbursement
At the end of each month you will receive a document called a Superbill that you send directly to your insurance company at the end of each month. The Superbill details how many sessions you’ve had, and the total fee. Once you submit the Superbill and depending on your specific plan, your insurance company will then mail you a check to reimburse a portion of that cost.
Note: Using an app like Reimbursify can help you navigate the reimbursement process in a few clicks