Insurance Reimbursement
when using
Out Of Network
Still unsure about using your out-of-network benefits? Use the following steps to learn how out-of-network benefits work and how you can work with an out-of-network therapist. We’ll also talk about how to get an out-of-network reimbursement paid. Though navigating out-of-network benefits can be cumbersome, it can save you a lot of money in the long run. Even if you don’t fully understand the terms below, having the details upfront can help you figure out how payment works, and prevent any unexpected bills.
It’s also helpful to contact your insurance company’s member services for specific instructions related to their reimbursement process, as procedures can vary widely between providers.
Be prepared, Know the process before you begin
When navigating the intricacies of insurance, a little preparation goes a long way. Always have a pen and paper handy. Take note of the number you called, the names of the representatives you spoke to, and the date and time of your call. Make sure to jot down important details, including reference and case numbers. Patience is key, as the system can be complex and customer service representatives are working hard to assist you. Don’t hesitate to ask for clarification on anything you don’t understand, and always get a name and reference number for your records.
Here are the steps
1. First, make sure you know 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.
2. Call your insurance company to verify your benefits and ask these questions
The best way to be sure of your benefits is to clarify information with your insurance company member services line. You can find this phone number on the back of your insurance card or through your online insurance platform.
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 such as therapy sessions.)
- 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 out-of-network reimbursement? (Claims are forms that are sent to your insurance company to receive reimbursement for sessions you paid for out of pocket.)
Other questions that are beneficial to know
- Are the following codes are covered: (get the codes from them or your provider)
- Example
- 90837 Individual psychotherapy 54-60 minutes
- 90847: Couples therapy – If applicable
- Is a diagnosis required for reimbursement?
- Do they cover psychotherapy via telehealth or online therapy ?
- Is a Licensed Marriage and Family Therapist a covered provider? – You can give them mine if they need the number (about me page)
- Write this information down. If applicable, ask them how much of your deductible has been met to date and what date does the deductible start/end (usually Jan 1 to Dec 31).
- Is there a maximum out-of-pocket limit and if so, once you reach that, what is the reimbursable amount and will they cover 100% after you reach that?
- Is any prior authorization, pre-certification, or approvals needed? Who needs to make these (doctor, the therapist, psychiatrist?)
- Is there a visit limit?
Ok - Let's Pause - For Plain Speak
If the therapist you’re seeing is not in-network with your insurance, then you will have to pay for the session upfront. Fortunately, depending on your health insurance plan, your insurance company may help reimburse a portion of the cost by mailing you a check or depositing money into your account. If you have a PPO or POS health insurance plan, you’ll get back partial reimbursement for out-of-network services, making seeing an out-of-network therapist more cost-effective and budget-friendly.
3. Ask your therapist for a Superbill
When you’re looking for a therapist, ask if they are willing to submit claims to your insurance company for reimbursement. While some therapists offer this, typically, the client is responsible for submitting claims (learn more about different billing options here.)
A superbill is typically a PDF or one-page receipt that a provider (or therapist) generates for clients. Insurance companies may ask for it from patients in order to get reimbursed for services using their insurance benefits. A superbill includes specific pieces of information, such as when a therapy session occurred and the patient’s diagnosis code
4. Receive out-of-network reimbursement!
You’ll pay your therapist the entire session fee at the time of service, but depending on your specific plan, your insurance company will mail you a check to reimburse a portion of that cost. There are even apps for that! Using an app like Reimbursify can help you navigate the reimbursement process in a few clicks.
Get Reimbursement Off Your Mind with Reimbursify:
We make “out-of-network” healthcare a breeze.