Quick Guide to Navigate Out-Of-Network Mental Health Insurance Benefits

Insurance has gotten very complicated! Hopefully, I can help answer some of your questions regarding how to learn more about your out-of-network mental health insurance benefits here.
 
Often, we may try to utilize our insurance benefits by seeking out an in-network provider. However, it is often the case that most clinicians that are in-network are full and not accepting new clients especially in larger cities. Seeking out an out-of-network provider provides you a greater opportunity to find a clinician who is accepting new clients.
 
If you decide to work with an out-of-network provider, you will need to pay the full session fee at the time of the meeting.
 
Many insurance plans provide partial reimbursement for behavioral health services. This makes working with your therapist of choice more affordable.  Many therapists provide monthly superbills that you can submit to your insurance for potential reimbursement. Superbills are basically an invoice that you submit as a claim to your insurance provider.
 
 

Some basic definitions of insurance terminology that will be helpful for you to understand your benefits.

  • Out-of-network deductible: This is the amount of money you have to pay before your insurance benefits kick in. For example, if your deductible is $1000, you would have to pay for services until this amount is met, then your benefits would kick in and you would be responsible for the copay or co-insurance rate for that service moving forward. If therapy was $200/session, it would take you 5 sessions to meet your deductible, then your copay or co-insurance would go into effect.
  • Out-of-pocket max: This is the total amount of money you have to pay yearly for all insurance costs (deductibles, copay, co-insurance, etc.) This applies only to some insurance plans which means that some insurance plans don’t count money spent out-of-network towards the out-of-network max while others may have a separate out-of-network out-of-pocket max.
  • Copay: A fixed amount that you pay per service.
  • Co-insurance: A percentage of a cost that you pay per service. For example, if your co-insurance was 30%, after you meet your out-of-network deductible, you would owe $30 if the service fee was $100.
  • Pre-Authorization: Some insurance plans require pre-authorization for certain services tied to billable codes. If so, you would need to find out what this process entails and may require the therapist to call your insurance to request a pre-authorization to provide a service tied that that specific code.
 

To learn more about your out-of-network benefits, please call the number on the back of your insurance card or call the insurance benefits department and ask to verify your benefits for outpatient mental health/behavioral health office visits and ask the following questions.

 
1. What are my out-of-network benefits for outpatient mental health visits?
2. What is my out-of-network deductible? How much of my out-of-network deductible has been met this year?
3. Do I have an out-of-network max? If so, what is this amount?
4. What is my out-of-network copay or co-insurance for outpatient mental health visits?
5. Do I need a pre-authorization for the following codes:
  1. 90791 (Initial Assessment)
  2. 90837 (50-minute session)
  3. 90384 (45-minute session.

6. Is there a limit to the number of sessions my plan will cover?
7. Is telehealth approved?
8. How do I submit claim forms for reimbursement?

There are so many reasons why you may prefer to work with a therapist who is not in-network with your insurance plan. Hopefully, this step-by-step process helps provided you with a solid foundation to obtain the information you need to utilize your out-of-network insurance benefits!

Hi, I’m Arati Patel, a licensed marriage and family therapist with a passion for helping individuals heal, feel calm, and move towards wholeness. I have specialized interests in working with anxiety, stress, fear, self-doubt, first generation issues, cultural stress, and identity issues. I currently have a private practice in Los Angeles, CA.

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