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

 

Call the customer service number listed on the back of your insurance card.

Here are some questions you may want to ask:

 

  • 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? 

  • 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?  {This answer is almost always "no".}

  • Is there a maximum number of session I am covered for each year?  {This answer is almost always "no."}

  • What is the "allowed amount" for CPT code 90837 {or, in other words, how much of the $140 session fee will be reimbursed}?

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

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

Other than United Healthcare and HMSA, I am an out of network provider. That means that I am not participating on any insurance panel.

 

Upon request I will issue 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 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 I will provide you with a statement of services rendered.

HEALTH INSURANCE AND CONFIDENTIALITY OF RECORDS

If you use your insurance 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, privacy or to future capacity to obtain health or life insurance or even a job.

 

The risk stems from the fact that mental health information is likely to be entered into big insurance companies’ computers and then to be reported to the National Medical Data Bank.

Accessibility to companies’ computers or to the National Medical Data Bank database is always in question as life insurance and health insurance carriers will typically require a person seeking insurance to allow them access; an employer will typically require a job seeker to allow them access; and, in addition, computers are inherently vulnerable to break-in’s and unauthorized access.

 

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.