How and when to use out-of-network insurance benefits

Sep 24

We know therapy and traditional medicine are vastly different from each other - yet they’re still included on the same insurance plans and as part of the same medical system. However, therapists are somewhat famous (more so than other providers) for not accepting insurance, and only accepting “private pay” clients who pay out of pocket.

This doesn’t mean you can’t use some insurance benefits. You can still use out-of-network benefits, but you should be sure to check a few boxes first.

Do your research about the out-of-network benefits specific to your provider and plan.

Check your coverage.

You can typically call your insurance or go online to a member portal to check your benefits. You’ll want to specifically ask your insurance company what your out of network benefits for a mental health provider are.

There are different categories of care, such as inpatient or outpatient. You’ll be asking about outpatient psychotherapy. If you want to be even more specific, you can provide the billing code to your insurance provider and ask them about out-of-network benefits for that code. Your typical therapy session is billing code 90837.

Out-of-network benefits typically do not cover an entire session fee, and will reimburse you for a percentage. There may be a limit on how many sessions you can be reimbursed for. Some networks do not provide out of network benefits at all, so don’t assume that you’ll be able to get back any costs. Do the research upfront so there aren’t any surprises.

Another note to keep in mind is that even within an insurance network, some plans may provide out of network benefits while others do not. Know your specific plan, and confirm with your insurance provider before incurring costs you may not be able to recoup!

Understand the upfront costs and payment cycle.

When you use out of network benefits, you are still responsible for paying the entire session fee due to your therapist at the time of service. This means money out of your pocket until your insurance company reimburses you.

When you talk to your insurance company about out-of-network coverage, be sure to ask them how long it typically takes to receive your reimbursement after a claim. You can also ask how you’ll receive it - a check? An electronic deposit? This way, you’ll know exactly what to expect.

Know how to file your out of network claim.

In this day and age, you’ll likely be able to file your claim online. You may also be able to mail it in, fax it, or call your insurance company.

You will definitely need to provide a superbill, but make sure that you are aware of any other paperwork or documents that you may need to provide.

A superbill is not an invoice - it’s not money that you owe. Instead, it details for your insurance company the money you have already spent on care, and allows you to seek reimbursement for all or part of this expense.

Let your therapist know you need a superbill.

You should mention this upfront and confirm with your therapist that they can provide one and that they are licensed appropriately to be eligible for insurance reimbursement. Many insurance networks will not reimburse for clinicians who are not yet fully licensed and are finishing their licensing supervision hours. At Open View, I am fully licensed and eligible for insurance contracting and reimbursement. Note that even when a counselor can provide you a superbill, they can't guarantee reimbursement- it's ultimately up to the insurance company!

Telling your therapist that you need a superbill will also make them aware of any other information they need to provide, such as a diagnosis. Most insurance companies require a diagnosis (and medical necessity) for any coverage - out of network benefits included. (Read about what to know when using insurance for therapy).

You can also ask for a superbill after each session, or monthly, depending on how often you want to submit your claims and get reimbursed.

Attend session, get your superbill, submit!

Once you are confident in your details and coverage, you can attend therapy sessions feeling confident about how you’ll cover the costs.

You will pay your full session fee at the time of service, and then take your provided superbill and submit a claim to your insurance for reimbursement.

When to use your out-of-network benefits

Out of network benefits can be helpful when you’d like to work with a therapist who doesn’t take insurance at all, or who takes insurance but not your insurance. For example, I have a contract with Cigna but not Blue Cross Blue Shield; someone who has BCBS but wants to work with me could use their out of network benefits.

Recap: What to ask your insurance

What are my out-of-network benefits for outpatient psychotherapy?
How do I submit a claim for reimbursement?
How will my reimbursement be given to me?
How long will it take to receive my reimbursement?
Is there any limit to how many sessions I can be reimbursed for?

Recap: What to ask your therapist

How much will each session cost me out of pocket?
Can you provide me with a superbill (weekly or monthly)?
Is your license eligible for out-of-network insurance / insurance coverage? Even if it is, a therapist/counselor cannot guarantee your out of network reimbursement - it will be up to the insurance company.