Out of Network benefits mean that instead of paying a co-pay like you would with an in-network provider, you pay the provider’s fee up front at the time of service. We then generate what’s called a “superbill”, which is a receipt for services rendered, that you then are able to submit to your insurance company (typically through a member portal online). If you have OON benefits, your plan would reimburse you directly - usually a percentage of the fee you paid up front.

The best way to find out about your out of network benefits is to call your insurance plan. The member services number on the back of your insurance card will connect you with a representative that can give you the details of your plan. See below for a list of questions to ask when calling.

Typically, if your insurance card includes words like “personal choice”, “preferred provider” or "PPO,” that means you have out of network benefits. If your insurance card includes letters/words like “HMO,” that likely means you do not have out of network benefits.

A superbill is an itemized receipt of the services provided by your therapist. It will include the date of the session, a service code (which tells the plan how long & what kind of appointment was held), cost of the session, and a diagnosis - we are required by the insurance companies to give you a psychiatric diagnosis to prove “medical necessity”. It will also show your full name & date of birth, and/or the name & DOB of the “responsible party”, which would be the policy holder and person in charge of payment.

You’ll also see information about the practice and your individual therapist. The insurance plan needs their license number, their National Provider Identifier (NPI), and the practice’s contact information and Tax Identification Number in order to know who you saw and why.

We send these out monthly via email for your convenience.

A deductible is an amount set by your insurance plan that they require you meet before they’ll pay anything towards care. This amount resets when your plan does (typically January 1st). Your plan will likely say something like “you have a $3,000 in network deductible and then 50% co-insurance”, which means you would need to pay $3,000 and then your plan would pay 50% of what you paid out of pocket.

What this means for out of network providers is that you’ll pay your therapist’s fee up front each time, and when you submit your superbill that total amount will go towards your deductible. For example: If your deductible is $2,000 and your therapist’s fee is $200/session, in 10 sessions you would have met your deductible and your plan would start paying ($200 x 10 sessions = $2,000). You would continue to pay the $200/session, but your insurance plan would send you a check for a percentage of that cost.

If you are on a plan with others from your family, you may have a family deductible instead of an individual one. This means that all members of the plan pay towards that deductible for their medical care, so it’s possible that the deductible will be met quicker or may have already been met.

Service codes, also called Current Procedural Terminology (CPT) codes, are a uniform series of numbers that indicate what treatment was provided and for how long. These are used across all medical settings when interacting with insurance. Some common ones we’ll use are:

90791: Psychiatric Diagnostic Evaluation (For first appointment)
90837: 60 minute psychotherapy
90834: 45 minute psychotherapy
90847: Family Psychotherapy with patient present
90846: Family Psychotherapy without patient present
90832: 30 minute psychotherapy (would only be used if session is cut short for any reason)
73802 Medical Nutrition Therapy; initial assessment & intervention
73803 Medical Nutrition Therapy; re-assessment & intervention
96170 Health behavior intervention, family, without patient present
S9470 Nutritional counseling, Registered Dietitian, initial assessment

1. Do I have out of network benefits for outpatient mental health services?

2. Are telehealth services eligible for reimbursement (if applicable)?

3. Do I need a pre-authorization to use my OON benefits? If yes, What does that process look like?

4. What is my deductible? Is it an individual or a family deductible?

5. What percentage of the fee is reimbursed after the deductible is met? Is this percentage calculated from the therapist’s fee or a “usual and customary” rate?
**A ‘usual and customary’ (UCR) rate is a dollar amount set by the insurance company, and difficult to obtain from them. If your plan reimburses based on the UCR amount instead of the therapist’s fee, the amount you receive may be less. For example, if your plan says they’ll reimburse 50% and your therapist’s fee was $200, you would receive $100 back (after the deductible was met). If they are using the UCR rate, we would assume it’s less than $200 which means your reimbursement would be less.

6. What is the process for submitting superbills?

7. How long does the reimbursement process take?

8. Are there any services you don’t reimburse for?

9. Is there a time limit on how long I have to submit?

10. Do I have a limit on how many appointments I can have with this provider?

If a superbill is denied you will be given a reason (called a denial code) and an action step to fix it. Most denied claims can be avoided by asking the above questions so you fully understand your plan and its requirements.

Some common denial reasons include:

• Missing or incorrect information on the superbill: If your name is spelled incorrectly, date of birth doesn’t match what’s in the system, it’s missing a diagnosis, etc. This error will be clearly spelled out for you in the denial code, and you should contact us to rectify the mistake and send a new superbill
• Your plan required a pre-authorization: You should immediately contact the pre-auth department to fulfill this requirement. You may be able to back-date a pre-auth by negotiating with your plan, which would allow them to reimburse for services already rendered.
• Not a Covered Benefit: The denied claim may include a benefit that is not covered by your plan—this is sometimes called an “exclusion.” Your plan will not pay for services that are not covered, even if you have out-of-network benefits. Ask about any non-covered services during your phone call.
• Not Medically Necessary: Each plan has its own definition of what is medically necessary. For most plans, medically necessary care does not mean the best possible care, but care that meets the standards of good medical practice for treating a particular condition. For this type of denial, your plan determined that there were not enough medical records to support payment of your claim or that you did not meet the plan’s medical criteria for coverage. This can include services that the plan may consider investigational or experimental.
  • If you receive this denial code, contact your plan to better understand the determination and your options for appealing it. Your plan may ask you to submit medical records or “proof” of medical necessity. Your therapist would provide you with the documentation needed for you to submit - this could include details of your treatment with the provider. Record releases are charged at the hourly rate, and prorated based on amount of time spent.
• The claim was not filed in a timely manner: some plans have time limits on when you can submit for reimbursement, be sure to ask about this during your call. Best practice is to submit soon after receiving the superbill from us.
• Failure to respond to communication: If you receive any communication from your insurer with a specific request for information and you fail to respond, the insurer may deny reimbursement. This could be a secure message through your insurance portal or a phone call. Contact your plan to find out what information is needed and submit.
• Policy canceled for lack of premium payment: call your plan to pay the balance and ask for the superbill to be reprocessed.
• The benefit has been exceeded: If your plan has a visit maximum for mental health services they will stop reimbursing once you’ve exceeded that limit. Be sure to ask about this when calling, and you can track the number of sessions in your insurance portal.