Out of Network Reimbursement
insurance is confusing.
i created this guide to help you if you want to see a private pay/cash therapist and seek reimbursement after.
The Basics of Health Insurance
Health insurance is an agreement between you and an insurance company.
When you have health insurance, you pay a certain amount of money called a premium each month. In return, the insurance company helps pay for your medical expenses when you get sick or injured.
In-Network vs. Out Of Network
When a therapist, doctor, hospital or other provider accepts your health insurance plan they’re in-network or a participating provider.
When you go to a therapist, doctor or provider who doesn’t take your plan, they’re out of network (OON).
OON is also referred to as private pay, cash, or fee for service.
The two main differences between them are cost (it’s cheaper to go to an in-network provider) and whether your insurance plan helps pay for care you get from OON providers.
As an OON provider, I do not accept insurance directly. However, many Preferred Provider Organization (PPO) insurance plans offer OON benefits that help clients get reimbursed for therapy (20-40%) after meeting your deductible (not guaranteed). Once you meet your out-of-pocket maximum, therapy/medical treatment will be covered at 100%.
Deductible: Amount of money you need to spend out of pocket before your insurance starts paying some of your health care expenses.
Out-of-pocket maximum: The most you'll ever spend out of pocket yearly. Once you spend enough to reach your plan’s maximum, insurance will cover 100% of your medical bills.
Click here for a list of commonly used terms with insurance companies.
Deductibles reset every year beginning January 1st.
If you have an Health Maintenance Organization (HMO plan), you do not have OON benefits.
How Do I Know If I Have OON Benefits?
If you have an Health Maintenance Organization (HMO plan), you do not have OON benefits.
Call the number on the back of your insurance card to talk to a customer service agent on the phone.
Send a secure message on your insurance portal to write to a customer service agent. I prefer this method because I have written documentation.
You can also log onto your insurance client portal and view your benefits instead of calling insurance.
Review your health insurance benefits plan document.
Click here for an example of a plan benefit summary from Regence.
Click here for an example of a plan benefit summary from Premera.
Questions To Ask Insurance
Please check directly with your insurance company and specific benefit plan (every plan is different).
Options
Copy and paste the questions below and send a message on your online insurance portal. This is my preferred method as I have written documentation and have it for reference.
Call your insurance plan and speak with someone on the phone.
Questions
Do I have mental health insurance benefits?
Do my benefits cover telehealth/online therapy services?
Does my plan cover out-of-network (OON) providers?
Do I have a restricted number of visits per year for mental health counseling? If yes, how many visits?
Will I be reimbursed for seeing a licensed independent clinical social worker (LICSW?)
Will I be reimbursed for seeing a licensed psychologist (LP)?
Will I be reimbursed for seeing a licensed mental health counselor (LMHC)?
Will I be reimbursed for seeing a licensed marriage and family therapist (LMFT)?
Will I be reimbursed for seeing a licensed psychiatrist (MD)?
Will I be reimbursed for seeing a licensed Psychiatric Mental Health Nurse Practitioner (PHNMP)?
How much of the fee is reimbursed for OON master’s level providers for the following services: 60-minutes First Session/Intake: 90791, 60-minutes: 90837, 45-minutes: 90834
What is your usual and customary reimbursement rate for CPT codes 90837 and 90834 in zip code 98177?
What is my deductible for OON benefits? Have I met my deductible for OON benefits?
Are there any differences between billed charges and allowed charges when the service provider is OON?
What documentation do I need to submit to receive OON therapy reimbursements for OON providers (documentation, diagnosis, provider NPI number, etc.)?
How long will it take to be reimbursed for sessions after I have submitted my claims for out-of-network benefits?
Is approval required from my primary care physician or do I need a referral from an in-network provider?
(For couples counseling). Will Z Code “Z63.0, Relationship Distress With Spouse or Intimate Partner” be reimbursed?
Example of OON Reimbursement
You have a PPO plan with an OON deductible of $1,000 a year, an out-of-pocket maximum of $4,000, and 40% coinsurance for OON therapy providers.
Your PPO plan includes coverage for mental health services and telehealth services.
You see me at a rate of $250 per 60-minutes.
Once you pay $1,000 up front for OON medical/therapy fees, you will pay 40% of medical/therapy fees ($100) and insurance will pay the remaining 60% ($150) or whatever the allowed amount your insurance plan pays for a 60-minute therapy session (could be anywhere from $60-$120) AND you cover the remaining fees/difference.
The exact fees/charges will depend on how much your insurance will pay for a 60-minute session (called the allowed amount). At most you would pay $160 per session and the least you would pay is $100 per session (depends on your insurance plan reimbursement rates and plan).
Once you pay $4,000 out-of-pocket for the year for medical/mental health expenses, insurance will cover 100% of remaining medical/therapy fees, meaning our sessions would be fully waived and you would pay $0 per session.
Note: Every insurance plan is unique and different. OON reimbursement is never guaranteed. It is your responsibility to check directly with your specific plan (e.g. coverage, rates, deductible).
Click here for an in depth explanation.
Important Numbers & Information
CPT Codes
60-minutes First Session/Intake: 90791 ($270)
45-minutes: 90834 ($200)
60-minutes: 90837 ($270)
License #: Licensed Independent Clinical Social Worker: LW61230640
Telehealth Services (inquire if your insurance covers teletherapy)
Diagnosis: This will be discussed during our first 1-3 sessions.
A Note If You Use Your OON Benefits
Please let me know if you want to use your OON and I will provide you with a monthly document with everything you need (NPI, License #, etc.)
A mental health diagnosis is required on your record/file. We will discuss this together.
You will receive a monthly document on the first of every day via the client portal.
Helpful Articles For OON Benefits
Resources For OON Benefits
Reimbursify will submit the insurance reimbursement paperwork for you. The first claim is free, and then they charge $2.99 per claim.
Do It Yourself: Every month, you’ll receive a statement from me to submit to your insurance company along with a claim reimbursement form.
Once you meet your deductible, you’ll receive a check in the mail for whatever you’re owed.
Why Don’t You Accept Insurance?
Click here to learn more.
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