What are Out-of-Network benefits?

Out-of-Network coverage allows you to be reimbursed for some of the cost of your therapy by your insurance provider. Many insurance companies have this type of coverage, which allows you to choose your own therapist, rather than to only see therapists covered by your company as In-Network.

 

How do Out-of-Network benefits work?

If your insurance company provides this coverage, you will pay for your therapy upfront at the time of your session, and at the end of the month your therapist will provide you with a “superbill,” which is a receipt of the sessions you paid for in that month. You will then submit this “superbill” to the insurance company, usually on a monthly basis, and they will mail you a check for the amount they will reimburse. 

 

Since you are responsible for all communications and dealings with your insurance company regarding Out-of-Network coverage, and will be responsible to pay for your sessions regardless of insurance coverage, it is very important to contact your insurance provider so that you can feel confident in your knowledge of what will be covered. Use the guide below to know how to contact your provider and what questions to ask:

 

How to check your out-of-network coverage and possible out-of-network benefits:

• Plan for 15-30 minutes of your time available to call your insurance company

• Make sure to have this information ready before your call:

  • Insurance card

  • Name, date of birth, address, phone number, or possibly social security number of the cardholder or person for whom the services are for

  • Pen and paper/notepad

• Questions to ask:

• • Are there out-of-network benefits for this policy?

  • Do I have a mental or behavioral health policy with out-of-network benefits?

  • What are the requirements to use out-of-network benefits?

  • Is prior authorization required?

  • Is a referral required from my primary care physician?

  • Do I have an out-of-network deductible?

    • If yes:

      • What is my out-of-network deductible?

      • How much of my out-of-network deductible has been met?

      • What is the start date of the calendar year my out-of-network policy is based on?

      • In addition, ask the representative if your policy covers this service/CPT code: Service: Individual Psychotherapy 53 minute session CPT Code: 90837. What is their “usual and customary” payment for this CPT code? What percentage of that do they cover out of network? 

• Other questions to ask:

• • Is there a session limit?

    • If yes:

      • What is the session limit?

      • How many sessions do I have left?

    • What percentage of services is covered/what is my co-insurance? 

• At the end of the call make sure to have:

• • Date/time you called

  • Representative’s name

  • Reference number for the call

Information that will be provided on your requested receipt of payment (superbill):

• Provider’s name

• Provider’s NPI

• Provider’s license number

• Federal Tax ID number

• DSM-5 and/or ICD-10 diagnosis codes

• CPT or Procedure codes