Getting Reimbursed for Therapy with an Out-of-Network Provider – Explained

The good news is you’ve found a therapist you want to start seeing. However, you’ve also discovered that the therapist is an out-of-network provider. An out-of-network provider is a healthcare provider that does not contract with your specific insurance company or any insurance companies at all.

If all of this has you feeling discouraged and uncertain about how affordable therapy will be, read on for the scoop.

If you have a PPO policy, you can use your out-of-network benefits and get back a percentage of the full session rate from your insurance company. Keep in mind, there are no guarantees of reimbursement because it is dependent on several factors and specific to each individual insurance plan. The following information will help you learn more about using insurance with an out-of-network provider.

Overview:

  1. Call insurance company to verify benefits
    • See below for more on this
  2. Attend session and pay out-of-network provider full session rate
  3. Request a superbill from therapist
  4. File claim with insurance company through their member website or portal
  5. Receive reimbursement from the insurance company

Verifying Your Benefits:

  1. Speak to a customer service representative, or preferably a supervisor, about your out-of-network benefits
    • “How much do you reimburse for out-of-network psychotherapy?”
    • “Is there a ‘maximum allowable amount’ per session?”
      • The “maximum allowable amount” is the amount typically considered payment-in-full
    • “How much is my deductible and how much of it have I met?”
    • “Do I have a separate deductible for out-of-network providers?”
    • “Will you need anything aside from the ‘superbill(s)’?”
      • A “superbill” is similar to a receipt and provided upon request by your therapist
    • “Is there a difference in coverage for ‘parity diagnoses’ and does it change any of the above?”
      • “Parity diagnoses” are diagnoses which are typically covered without limit, based on medical necessity
  2. During the call with your insurance company, you may be asked the following information about your out-of-network provider at Recharge Online Therapy:
    • Type of Contract: Out-of-Network Provider
    • Type of Provider: Masters Level Clinician or MFT (Marriage and Family Therapist); Emily Sharaf, LMFT (License # 101706)
    • Type of Service: Individual Psychotherapy 45 minutes, CPT Code: 90834
      • The aforementioned CPT code is for video therapy, message therapy and/or matching sessions are not eligible for insurance reimbursement
    • Address of Service: Online Psychotherapy (Headquartered in Los Angeles, CA, Zip Code: 90046)
    • NPI: 1770934242
    • Type of Contract: Out-of-Network Provider
    • Type of Provider: Masters Level Clinician or MFT (Marriage and Family Therapist); Emily Sharaf, LMFT (License # 101706)
    • Type of Service: Individual Psychotherapy 45 minutes, CPT Code: 90834
      • The aforementioned CPT code is for video therapy, message therapy and/or matching sessions are not eligible for insurance reimbursement
    • Address of Service: Online Psychotherapy (Headquartered in Los Angeles, CA, Zip Code: 90046)
    • NPI: 1770934242

Considerations:

  1. Reimbursement can take several weeks (or months) to process and is not guaranteed
  2. In a lot of cases, insurance will not cover therapy services unless you have a moderate to severe diagnosis
  3. Your insurance company will be receiving information about you from your superbill
    • A superbill generally includes the following:
      • Your name, date of birth, address
      • Therapist’s name, tax ID, NPI, office address
      • The dates of service, CPT code and your diagnosis
      • The amount charged for session and amount you paid
  4. Past providing you with a superbill, most out-of-network providers do not communicate with insurance companies
    • You will be responsible for communication (and follow-up) with your insurance company

Although figuring out how to use insurance with an out-of-network provider is not always easy, it is possible. Educating yourself about the process, verifying your benefits and keeping considerations in mind will allow you to plan and execute accordingly.