How do I find out if I have "Out-of-Network" benefits?

• Do I have out-of-network behavioral health benefits?

• If yes, is procedural code (aka CPT code) 90837 {60-min psychotherapy session} with Modifier GT {therapy done online through telehealth} covered or 90847 {50 minute couples* or family therapy session}?

  • Some insurers do not cover Couples Therapy. Please confirm using that specific verbiage.

• If yes, is the telehealth standard for out-of-network behavioral health coverage, or just during Covid-19 response dates?

• Do I have an out-of-network deductible?

• If yes, is this deductible combined with my in-network deductible, or is it separate?

• How much of this deductible has been met this year?

• Do I have a co-insurance for out-of-network services once my deductible has been met?

• Is any pre-approval required before obtaining out-of-network outpatient behavioral health services?

• Is there a maximum number of sessions I am covered for each year?

• What is the "allowed amount" for CPT code 90837 (Individual Therapy ) or 90847 (Family or Couples Therapy*) {or, in other words, how much of the $135/165 session fee will be reimbursed}?

  • *Some insurers do not cover Couples Therapy. Please confirm using that specific verbiage.

• My therapist will give me a "Superbill" receipt each month. What is the reimbursement process for out-of-network claims?

Easiest Answer: Call the customer service number listed on the back of your insurance card.​​

When you call be sure to ask...

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• If you use your mental health benefits your insurance company will require that the I give you a at least one psychiatric diagnosis which indicates a mental disorder.

  • Example - Major Depressive Disorder, Post-Traumatic Stress Disorder, (PTSD) Generalized Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD), etc

• That diagnosis will remain in your medical record.

• Should you decide to use your insurance for reimbursement, I will provide you with a statement of services rendered.

WHAT YOU SHOULD KNOW ABOUT USING
IN-NETWORK AND OUT-OF-NETWORK INSURANCE BENEFITS

HEALTH INSURANCE AND
CONFIDENTIALITY OF RECORDS

• I am an out-of-network provider. That means that I am not participating on any insurance panel.

• Your therapeutic appointment includes a statement of payment (along with an appropriate diagnosis) for anyone who wants to use their insurance to get reimbursement.

• Although your insurance company may have mental health benefits there are a few things you should know regarding the use of those benefits:

• If you use your insurance for reimbursement, a disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims.

• I have no control or knowledge over what insurance companies do with the information submitted or who will have access to this information.

• You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality and your privacy.

• In addition, medical and mental health data has been reported to be legally accessed by law enforcement and other agencies, which may also compromise your confidentiality.

PAYMENTS

• Sessions are paid prior to the start of your session so that we can maximize your time.

• Please have your card handy to set up your payments if this is your first session.

• ​Failure to pay will result in a no-show fee.

Good Faith Estimate

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises