Using Out-of-Network Benefits
I am paneled with Blue Cross Blue Shield PPO and Aetna insurances. If you have a different insurance company and want to submit claims for reimbursement, here is information that may help you understand the process.
Please note: I am not part of the Medicare or Medicaid programs, so even if you have those through BCBS or Aetna, I would be considered out-of-network.
Definition list of commonly used insurance words:
Copay: the set/fixed amount you pay for a healthcare service, typically at the time of your visit. If your copay is $20, each therapy session will cost you $20. This cost generally stays the same whether you have hit your deductible or not.
Deductible: the amount of money you have to pay out of your own pocket for healthcare services before your insurance starts helping with the costs.
Coinsurance: the percentage of the therapy session bill you have to pay after you've met your deductible. If you have a 20% coinsurance (for a $175 session), As an example, you would pay $35 per therapy session. Generally speaking, you either have a copay or a coinsurance.
Out-of-pocket maximum: the highest amount you will pay in a year for covered services. After you reach this amount, your insurance will cover 100% of the costs for the rest of the year.
Out-of-network: the provider does not have a contract with your insurance company. Usually, you will pay more when you see an out-of-network provider.
Out-of-network benefits: the coverage your insurance plan offers when you receive services from providers that don't have a contract with your plan's network. You have to pay the entire amount yourself at first, and then your insurance will pay you back according to the rules of your plan for out-of-network services.
Out-of-Network deductible: This is the amount you have to pay out of your own pocket for services from providers that are out of your network before your insurance will start to help with the costs.
Allowed amount: the maximum amount your insurance will pay for a covered service. If your provider charges more than the "allowed amount," you'll need to pay the difference. As an example, your insurance may have an "allowed amount" of $150, even though the therapy session costs $175. You will initially pay the full $175. Your insurance will then reimburse you up to $150. The remaining $25 difference won't be covered by insurance (it will be considered your responsibility), meaning the session will cost you $25. Coinsurances are usually calculated based on the "allowed amount".
Superbill: a detailed receipt from your provider that includes all the necessary information for submitting a claim to your insurance. You use it to get reimbursed when you’ve seen an out-of-network provider.
Claim: a formal request you make to an insurance company asking them to cover costs/reimburse you for services or expenses you've had. It usually contains information about the services you received and the costs involved.
Policy period: the time when your insurance coverage is active. It starts on the date your policy takes effect and ends on the date it expires. During this time, you can access the benefits described in your policy. For many insurance plans, policy periods restart on January 1st.
Steps for Using Out-of-Network Benefits
Step 1: Determine if you have out-of-network benefits
Here are two ways to check to see if you have out-of-network benefits. You can either:
Check your insurance's website: Navigate to your insurance company's website and look for the Summary of Benefits. This is usually where you can find information about your out-of-network benefits.
Call your insurance company: Contact the Member Services phone number on your insurance card. I recommend calling your insurance company and asking them the following questions:
- Do I have out-of-network benefits included in my plan?
- Can I see an out-of-network provider for outpatient mental health/behavioral health services?
- What percentage of the fee will you cover for a 60-minute outpatient individual psychotherapy session (90837)?
- How much will I be reimbursed for a 60-minute individual psychotherapy session (90837)?
- What is my out-of-network deductible? How much of my out-of-network deductible has been met this year?
- When is my policy period?
- Are there any limits on the number of sessions or the total amount covered per calendar year? If so, what are they?
- Do I need a referral from an in-network provider to see someone out-of-network?
- How do I submit a claim for out-of-network reimbursement?
- How long do I have to submit a superbill?
- How long will it take for me to receive reimbursement?
Step 2: Pay for therapy then receive a superbill
When you meet with me for a therapy session, you’ll pay the full session fee directly to me at the time of the session. I will provide you with a superbill, which is a detailed receipt that you can use to seek reimbursement from your insurance if you have out-of-network benefits. I send these superbills on a monthly basis.
If you need the superbill sooner, just let me know.
Step 3: Submit your claim then get reimbursed
To file a claim, first review the out-of-network claim submission instructions provided by your insurance company. Insurance companies may have a preference for where/how to submit a claim; this can be online, through mail, or via mobile app. Create the claim using the superbills provided to you then submit when you're done. Remember to keep a copy of the superbill for your own records.
After you send in your claim, wait for your insurance company to process it. They should send you a reimbursement check based on your out-of-network benefits. If you see any differences or if the reimbursement amount does not line up with what was expected, contact your insurance company.