How to use Out-of-Network Benefits for Therapy

Your mental health is extremely important, for our own well-being and for those around you. Using your insurance provides a cost-effective way to get the benefits of therapy without the financial burden. However, maybe as you've started searching for the right therapist, you've found that a lot of therapists are "out-of-network". Why is this? And can you still get your insurance benefits?

Short answer: Insurance is tough but you can still get benefits while matching with the right therapist for you.

Long answer: A lot of therapists choose to be an out-of-network provider because of the limitations of billing directly through insurance, the cap on the number of sessions therapists are able to provide, a heavy amount of unnecessary overhead, not wanting to share protected information with your insurance company, and being told the type of therapy that is covered by insurance companies. For a lot of trauma therapists, the freedom to do as many sessions as necessary, while using therapeutic techniques that help move trauma from the body, is of the upmost importance. And to be candid, a lot of insurance companies do not cover this kind of therapy. Couples therapy and family therapy insurance coverage can be even harder to find.

Insurance companies require two things for coverage: a mental health diagnosis and a CPT code. Once both are given to an insurance company, the insurance provider will deem if treatment is "medically necessary". This means that if you are seeking therapy for grief, attachment in your relationship, relational concerns, personal growth, or anything that does not meet the criteria for a mental health disorder, your insurance company may very likely not agree to cover the cost of your therapy. Insurance companies usually do not consider couples counseling, family counseling, or adjustment counseling medically necessary, leaving you to foot the bill, regardless.

So...what's the way around this?

One possibility is something called a Superbill, or by using your out-of-network benefits.

Rather than having a therapist with a relationship with your insurance company and the therapist seeking reimbursement directly from the company, you have the relationship with the insurance company and seek reimbursement from the company directly. Your therapist will provide you with something called a Superbill, or a statement/receipt of sessions. This includes CPT codes, diagnosis, and session rates.

When you complete your intake forms, a credit card (or HSA card) will be kept on file and charged after each session. Then, when you request a Superbill, the statement will be generated and given to you for you to then submit directly to your insurance company for possible reimbursement. Reimbursement is not guaranteed, and you should always check with your personal insurance policy to see about out-of-network benefits, and possible reimbursement.

What's in a Superbill?

• Your personal information (name, address, date of birth).

• The therapist’s information (name, credentials).

• Date and duration of each therapy session.

• A list of services provided during each session.

• Diagnostic codes (ICD-10 codes) for your specific mental health concerns.

• The total cost of each session and any payments you’ve made.

Your therapist will document everything, and send you a superbill when you request one. Most places recommend getting superbills monthly, semi-annually, or annually, depending on your policy.

So, what are the steps?

Step One: Call your insurance company and check for out-of-network benefits

Step Two: Find a therapist you match with, and ask about superbills

Step Three: Attend sessions, asking for a superbill as needed (we recommend monthly or annually)

Step Four: Send your superbill to your insurance company

Step Five: Your insurance company will reimburse you directly

What questions should I ask my insurance provider?

First, call the number on the back of your insurance card and ask for member services.

• Do I have out-of-network coverage for mental health services, like counseling or therapy?

• What is my yearly deductible? And has it been met?

• Is there a limit on how many therapy sessions per year my plan covers?

• Does this include telehealth therapy?

• How much would I be reimbursed for an out-of-network therapists for CPT codes 90832, 90834, or 90837?

• Do I need a referral or approval from my PCP?

• How do I submit a superbill? Is there an online portal, fax, or physical address?

• What is the time limit for superbills and how often should I submit?

Keep in mind, you risk losing your potential reimbursement if you submit your superbill too late, so be sure to ask about frequency of submitting superbills and timeline. It can typically take 2-4 weeks for your insurance company to process your superbill, but ask your provider for more information. According to your personal plan, they may pay the full amount minus the copay, they may put this amount towards your yearly deductible, or they may deny your claim.

Talk with a Thorn & Rose Counseling therapist, and your insurance provider, for more information