Seeking Out-of-Network Reimbursement from your Insurance Company

 

Many insurance plans allow members to see any provider a member chooses, and will pay for some or all of that treatment. If your insurance plan does cover providers who are out-of-network, we can provide the required documentation so that some or all of your payments are reimbursed.

 

Do the Research

If you are considering using out-of-network benefits, it is wise to first contact your insurance company and ask the following questions:

  • Does my plan cover mental health sessions?

  • Does my plan cover only individual psychotherapy or will it also cover family or couples counseling?

  • How many sessions does my plan cover in a year? How many sessions do I have left?

  • Does my plan cover services to out-of-network mental health providers?

  • What is the deductible I have to meet before coverage to an out-of-network provider kicks in?

  • What is my copay or what percentage of treatment do I pay when seeing an out-of-network mental health provider?

  • Is there a maximum amount (per session) the insurance will cover for an out-of-network provider?

  • How much time do I have to file a claim for out-of-network services?

  • Do I need pre-authorization or a referral from my PCP to see a therapist?

  • If I need pre-authorization, do I need to call or does my therapist?

  • What is the process to get reimbursed for out-of-network services?

 

Please be very clear about the last question. Each insurance company will have a slightly different process and it is vital for the practice to know what information your company will need and what form your company uses so that you can be given the proper documentation for your claim.

 

Getting Reimbursed

We will provide you with a detailed invoice (called a "superbill") after each session, or monthly as agreed upon with your therapist. It contains all the information that most insurance companies require. If your insurance company requires that some other form be filled out, please have that form available for the practice to complete. Please know specifically what your insurance company will need from you so that the practice can provide you with the adequate documentation that you need. Once you have your documentation, you can provide it to the insurance company so that it will reimburse you for your payments.

 

We are happy to answer any questions you have about this process and support you in getting your claims paid if you have problems. Interacting with insurance companies can be confusing and there is no need to have an extra barrier in your life.

 

Should I Use My Insurance Benefits?

Be well informed when deciding to use your health plan to cover therapy. The unfortunate reality is that seeking mental health care through your insurance can sometimes have unplanned consequences. Insurance companies only cover care that is "medically necessary". This means, that they will typically only cover therapy for issues that have a recognized mental health diagnosis attached to them. 

 

Your provider will be required to submit a diagnosis in order for you to get reimbursed for any therapy that you engage in. When submitting a claim to your health insurance, you permit your provider to provide the clinical information that the insurance company requires to substantiate the medical necessity of your care. Thus, your diagnosis and the supporting evidence for that diagnosis becomes part of your health record. Some feel this is a risk that could potentially impact other areas of life that take your health record into account. Please be sure to talk with your therapist about any concerns before moving forward with a session. 

 

By choosing to not use insurance, you have more choice about who you see, how long you stay in therapy and what your therapy looks like. You also gain a higher level of privacy related to your health information.

 

When cost is an issue, you may need to use your health benefits to access services. Using health insurance may be the only way for you to get treatment. Ultimately, you can look at the advantages and disadvantages of each option and make an informed decision about what will be best for you.

 

© 2011-2020 Positive By Design LLC/David M. Harris, MSW, LCSW. All Rights Reserved.

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