How To Use Out-of-Network Benefits for Therapy
Disclaimer: this information is for educational purposes only. It is not legal or financial advice. I cannot promise or guarantee insurance reimbursement.
3/26/24 update: Whoa! What a big response to this blog! I’m so glad it’s helping folks better understand their out-of-network benefits. I created a PDF so you can print the blog and keep it alongside your favorite calming tea while you call insurance. Cheering you on!
Insurance is confusing! Every plan is different so it’s so important that you understand your benefits. If you’re interested in working with me or another therapist who is not contracted with your insurance plan, you may still qualify for some reimbursement from your insurance provider.
Here is a step-by-step guide to help you learn more about your out-of-network benefits:
Call the Member Services line, which is typically listed on the back of your insurance card
Explain that you are interested in seeing an outpatient mental health therapist who is not in-network with your plan. If you are interested in working with me, they may want specific information about me and my practice, which you’ll find listed at the bottom of this page.
Ask what your out-of-network outpatient mental health benefits are, including your deductible, your out-of-pocket maximum, copay/coinsurance, allowable number of visits, and the allowed amount.
Outpatient: treatment outside of a hospital
Deductible: amount you need to pay before insurance coverage begins
Out of Pocket Maximum: typically the amount you are responsible for each year before insurance begins covering services at 100%
Copayment/coinsurance: sometimes listed as a percentage, sometimes listed as a flat fee. The amount you are responsible for each appointment.
Allowable # of Visits: how many visits per year that insurance will cover
Allowed Amount: each insurance has their own fee schedule for services. Often this is lower than a provider’s rates. For example, insurance may only pay $100 for a 45 minute session, even though a provider may charge $150. So if your plan covers 80%, they will reimburse you $80 (80% of the $100), not $120 (80% of $150).
Ask which billing/service (CPT) codes that they cover. I most frequently use the following:
90837 - 55 minute individual therapy
90834 - 45 minute individual therapy
90832 - 30 minute individual therapy
90847 - family therapy with client present
90846 - family therapy without client present
Ask if a referral or prior authorization is required. If so, ask who can make the referral and who needs to complete the request for prior authorization. Make sure to jot down how the referral or prior authorization should be submitted (e.g. phone, fax, e-mail, etc)
Ask how to submit claims for reimbursement. A claim is a form that you said to your insurance provide so you can receive reimbursement for the fee you paid to the provider.
Document your phone call with insurance. Write down the name of the person you spoke with and ask for a call reference number. This is useful if there is confusion about reimbursement in the future.
Tips for Calling Insurance:
Set aside at least 30 minutes to make this call. There may be a wait and you don’t want to rush through your questions!
Have pen and paper ready or prep a spreadsheet so you can jot down the information you’re learning.
Don’t be afraid to ask lots of questions! Many people worry about sounding silly or stupid for needing additional clarification. Try to set those worries aside. You’re entitled to know your benefits!
If you receive pushback from your insurance provider, it may be helpful to emphasize that you need to work with an eating disorder specialist. Ask for a list of in-network therapists who specialize in working with people with eating disorders and who are accepting new clients in your area. If you insurance provider is not able to provide you with options, use this as evidence that you need to see an out-of-network provider.
My Process for Clients using Out-of-Network Benefits:
Before we begin working together, I will offer a loving reminder that it is your responsibility to understand your benefits. Unfortunately, it is impossible for me to understand every insurance provider and the different plans. That being said, if you have questions about what to ask your insurance, please let me know, I’m happy to be a sounding board to help you navigate insurance calls.
We’ll have our session. After session, I will collect my full fee.
After our session, I will send you a “superbill” which you can submit to your insurance provider. A superbill is like a fancy receipt that will include my practice information, your diagnosis, a billing code, and the amount you paid. Insurance will review the superbill to determine if you are eligible for reimbursement.
You can choose to submit the superbill to insurance for potential reimbursement. Some people choose not to submit the superbill to insurance for privacy purposes. Totally up to you!
Information about My Practice
Your insurance provider may ask you for the following information about my practice:
Provider’s Full Name: Alexis Hart Tobelmann, LMSW
Type 1 National Provider Identification (NPI) Number: 1942865803
Practice Address:
2232 South Main Street
Unit 102
Ann Arbor, MI 48103
Phone: 734-215-5233
Fax: 810-325-5952
The billing/service (CPT) codes that I most frequently use:
90837 - 55 minute individual therapy
90834 - 45 minute individual therapy
90832 - 30 minute individual therapy
90847 - family therapy with client present
90846 - family therapy without client present