How to check your out-of-network insurance benefits

Get ready for the call

Before you call, have the following information ready:

– Your therapist’s full name and their National Provider Identification (NPI) number. Ask your therapist for this information.

– Your health insurance card, so you have easy access to the insurance company’s phone number, your member ID, and any other plan details you may be asked about.

– Full name and date of the birth of the main insured. If you are insured under your spouse’s, partner’s, or parents’ health insurance plan, you want to have their name and date of birth at the ready.

Good to also have

Health insurance companies follow the medical model of care, and they may ask you which Clinical Procedure Terminology (CPT) codes your therapist will be using.

Here is a list of CPT codes I typically use:

90791 – Initial Assessment (used for our first session)
90834 – Ongoing individual psychotherapy 
90837 – Ongoing individual psychotherapy, 53+ minutes
90847 – Family psychotherapy (also used for couples therapy)

An important caveat

Insurance requires a diagnosis to pay for therapy. For 90847, one person in the couple has to have a diagnosable mental health condition (e.g depression, anxiety, etc.) for the insurance to pay for sessions. Insurance won’t pay for couples therapy where neither partner has diagnosable mental health condition. Same is true for individual counseling where you don’t meet the criteria for a diagnosis.

Questions to ask about out-of-network benefits

Once you get connected with customer service at your insurance company, ask the following questions about your out-of-network benefits:

1. Does my plan provide out-of-network benefits for outpatient mental health visits? Not all plans cover out-of-network mental health visits.

2. What is my out-of-network deductible for outpatient mental health? You’ll know how much money you need to spend on out-of-network services before your benefits kick in. I have seen plans with deductibles in the range of $1,000 to $9,000.

3. How much of my out-of-network deductible have I met to date? Finding out how much you’ve already spent will tell you how much more you’ll have to spend to meet your out-of-network deductible. For example, if your out-of-network deductible is $3,000 and you’ve spent $1,000 to date, you will need to spend $2,000 more before your out-of-network benefits kick in.

4. What is my coinsurance? After your out-of-network deductible is met, coinsurance is your share of the cost. Let’s say each therapy visit is $250 and you have a 40% coinsurance. This means your insurance company will reimburse you for 60% of the session fee, which is $150. After reimbursement, your true out of pocket fee comes to $100 per session.

5. How do I submit claims for out-of-network reimbursement? To submit claims for reimbursement, your therapist will provide you with a Superbill. A Superbill is a detailed receipt that includes dates of sessions, a diagnosis code, a CPT code, and your therapist’s NPI and EIN numbers. To get reimbursed, you’ll need to submit the Superbill to your insurance company.

6. How much time do I have to submit for reimbursement? Each insurance company may be different. The usual is 90 to 180 days from the date of service (the date of your session).

Claim submission help is available

That’s a lot and for some people having this conversation with their insurance company can be overwhelming.

There are services that check your out-of-network benefits for you and will submit claims for reimbursement. Reimbursify, Mentaya, Advekit are just some of the companies out there that can help.

I work with Mentaya to help the clients I work with submit for out-of-network reimbursement. 

Signing up for a Mentaya account only takes a couple of minutes. They charge a 10% service fee for insurance reimbursements. If your claim doesn’t get reimbursed, Mentaya refunds their service fee to you.