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.
- 90791 (Initial Assessment)
- 90837 (50-minute session)
- 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?