Out-of-Network Benefits

I do not directly accept any insurance plans and you will incur the full service fee after each session. However, most of the time, clients who are paying for their healthcare costs out-of-pocket may not be aware of the fact that many health insurance plans also have out-of-network benefits. If your health insurance plan has out-of-network benefits, your final out-of-pocket costs could be significantly lower because you can submit claims for your sessions to receive reimbursements from your health insurance company. I prepared this step-by-step guide to provide you more information on how to learn about your out-of-network benefits and get started with receiving reimbursement from your insurance provider.

1. Confirm your out-of-network benefits

Every year, your employer or your insurance provider will send you a Summary of Benefits & Coverage document, which can be a good starting point to explore your out-of-network benefits. However, such summary documents are often confusing and non-conclusive. I recommend you to call your insurance company through the phone number at the back of your insurance card and ask them about your out-of-network benefits for outpatient mental health care.

Here is a short list of information they may ask you before providing you a concrete answer:

  • Benefit type: Outpatient mental/behavioral health
  • Place of service: Office
  • Procedure/CPT Code:
    • Individual therapy: 90837
    • Couples therapy: 90847

And here are the descriptions of the terms they may use in explaining your out-of-network benefits:

  • Deductible: This is the amount of out-of-pocket payments that you will need to make every year before your insurance begins reimbursing you for services. Please note that this is the total amount for all of the out-of-network services you receive, not just therapy.
    • Important note: even though your insurance will not begin reimbursing you before you meet your deductible, you should still submit your out-of-network claims for each session because if you do not submit your claims, the amounts you paid for your services will not be applied to your deductible.
  • Co-insurance: This is the percentage of the total service fees your insurance will be reimbursing you after your meet your out-of-network deductible. Often times, the call center employee will provide you two percentages such as 60%-40% or 70%-30%. In this case, the first number is the percentage they will cover. For example, if you already met your deductible, you are paying $200 for your sessions, and your insurance plan covers 60% of your services, you will receive a $120 reimbursement check for each out-of-network claim you submit.
    • Important note: Some insurance providers may have maximum allowed amounts for specific services. For example, if your plan has a maximum allowed amount of $150 for an individual therapy session, they would only reimburse 60% of this amount, which means that you would receive a $90 reimbursement check instead.

2. Download your Superbills after paying for your services

Each month, my secure client portal SimplePractice will automatically generate a superbill for you and send it to you via email. This superbill looks much like an invoice, but it also includes important information for your insurance provider to understand the services you received (e.g., service code, duration, NPI number). When you are to submit claims for out-of-network benefits, your insurance provider will ask for these superbills. So, make sure to download and store your superbills after each session.

3. Submit your out-of-network claims

The last step in using your out-of-network benefits is to submit out-of-network claims. There are two ways to do so. The first way is to use the system defined by your insurance provider, which will probably require you to download and print a form, sign it and snail mail it. I believe that this is not a good option because even finding the correct forms on insurance company webpages maybe difficult, and filing them correctly may be even more tedious.

If you are planning to use your out-of-network benefits, I strong recommend you to explore the following service instead of your insurance provider’s own forms:

I am unable to endorse this company personally as each insurance plan may have widely different out-of-network benefits and each person’s experience may be different. However, I have anecdotal experience that they are very good at their job and using a service such as Reimbursify is much much easier than trying to prepare claims by hand.

I hope that you found this guide helpful.