How to Use Out-of-Network Benefits for Therapy

Therapy is an important investment in your mental health, your overall well-being, your relationships, and your future.

And matching with the right-fit therapist is vital. But what if the right-fit therapist isn’t within your insurance network? 

You don’t necessarily have to settle. You may have options.

If you have questions about using your out-of-network benefits for therapy, keep reading to explore some Frequently Asked Questions and give your insurance company a call to better understand your coverage.

 

How do I use my insurance with Mend Modern Therapy?

 

By utilizing out-of-network benefits.

Rather than your therapist having a relationship with your insurance company and your therapist seeking reimbursement directly from them, you  have the relationship with your insurance company and seek reimbursement from them directly. Your therapist will provide you with everything you need to give to your insurance company.

When you complete intake forms before therapy begins, you’ll be providing a credit or debit card that will stay on file. This card will be charged after each session. So you are paying for therapy directly upfront. 

Additionally, you will be given a form called a superbill that you can submit to your insurance company for possible reimbursement. 

As an out-of-network provider, Mend Modern Therapy is not contracted with your insurance. Any reimbursement you hope to get from your insurance company is not guaranteed unless specifically outlined in your policy. If you are hoping to be reimbursed for the cost of therapy, you are encouraged to contact your insurance company directly to inquire about your out-of-network coverage before beginning services with Mend Modern Therapy.

If at any time you would prefer to seek services with a therapist within your insurance network, Mend Modern Therapy will assist you with referrals.

3 Easy Steps to use your out-of-network benefits:

1. Call your insurance company. See list of questions to ask them below.

2. Send your insurance company the receipt (aka “superbill”) that your therapist provides you.

3. Your insurance company will reimburse you directly for what you paid for therapy.

What questions should I ask my insurance company before starting services with Mend Modern Therapy?

 

You’ll want to call the number on the back of your health insurance card, and ask for “member services.” 

 

Here are some questions you can ask about out-of-network coverage:

 

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

 

• Does this coverage include telehealth (virtual therapy)?

 

• What is my yearly deductible?

 

• Has my deductible been met? If not, how much more is needed to meet my deductible?

 

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

 

• According to my plan, how much would I be reimbursed for an out-of-network therapist for *CPT codes 90834 and 90837 with the telehealth modifier?

 

• Do I need prior authorization to see a therapist?

 

• Do I need a referral or approval from my primary care provider to see a therapist? 

 

• To what address would you be sending checks? (Verify your insurance will send YOU reimbursement checks and NOT your therapist.)

 

• How do I submit a superbills? Is there an online portal, fax, or should I send them via email or snail mail?

 

• Is there a time limit to submit a superbill? 

 

*CPT codes refer to the type of service you received. CPT code 90834 refers to a clinical 45 minute session, and CPT code 90837 refers to a clinical 60 minute session. A clinical hour is typically 50 minutes. 

 

Is relationship counseling or couples therapy covered by insurance?

 

Insurance does not typically reimburse couples therapy.

 

Some issues or codes are not typically covered by insurance. These codes can include problems in relationship with spouse or partner (Code Z63.) For this reason, couples therapy is not typically covered by insurance, but be sure to check with your insurance about your specific out of network coverage.

 

Insurance companies generally require a mental health diagnosis to prove that your therapy is “medically necessary.” This means, if you are seeking therapy for grief, having issues in your relationship, or personal growth without meeting the criteria for mental health diagnosis, your insurance may not agree to cover the cost of your therapy. Since insurance companies usually don’t consider couples therapy to be medically necessary, couples therapy is not typically reimbursed by insurance providers. But since insurance plans differ, it is recommended that you talk to your insurance company about specific coverage for couples therapy.

 

What paperwork will I need to submit to my insurance company? 

All you need is a form called a “superbill.”  And each month, a superbill will automatically be generated and accessible in your client portal with Mend Modern Therapy.

A superbill is a document, much like a receipt, that includes your therapist’s information and the services you received and paid for. The superbill is automatically generated by our electronic health system and uploaded to your client portal on a monthly basis. The superbly will include the following information in order to be considered for reimbursement:

 

• Your name, mailing address, and date of birth 
• Name of your therapist with their phone number and email address
• Provider information of your therapist: eg, their Tax ID and National Provider Identifier (NPI)
• Statement number and date of issue
• A diagnosis and diagnosis code (also called a CPT code) 
• Service type, date, and code for reimbursement 
• The amount that you paid for the service

 

Are there any downsides to using insurance for therapy?

 

Possibly. If you’re exploring your options, it’s important to consider the following:

Insurance reimbursement may require a mental health diagnosis. Insurance companies often require therapists to diagnose clients with a clinical diagnosis as classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) and the International Classification of Diseases (ICD-10). 

Examples of diagnoses and their codes may include:

• Post-traumatic stress disorder
• Major Depressive Disorder
• Generalized anxiety disorder
• Borderline Personality Disorder

 

Can having a mental health diagnosis affect me negatively?

It shouldn’t, but…

Unfortunately, it can. According to the National Alliance on Mental Illness (NAMI), “Stigma does prevent people with mental illness from getting a job.” NAMI reports, “People with mental health conditions are typically held responsible and blamed for their behavior and symptoms. Simultaneously, they are perceived as unable to make decisions for themselves. This causes people with mental health conditions to be perceived as unsuitable for the workforce.”

If you have questions about your diagnosis or have concerns about receiving a diagnosis, please bring this up to your therapist at any point in the therapeutic process.

 

How do I submit my superbill?

 

You’ll want to check with your insurance company about their policy regarding the time limit to turn in your superbill. The policy may be included under “timely filing.” You may find this information by checking with the “member services” department or your insurance company’s website.

Typically, there are 3 options for turning in a superbill: online portal, mail, or fax.

 

• Online portal – It’s common for insurance providers to have an online portal through which you can upload your superbill. This option may be more secure option to send your superbill as you should be able to create a login and password. So, be sure to ask your insurance about this option. 
• Mail – Another option is to ask your insurance for a physical address to mail the superbill. You’ll want to allow time for delivery so that you stay within your timely filing limit. 
• Fax – Fax receipts may include private health information, so please take that under consideration if you do choose to fax your superbill. 

 

What can you expect after you submit a superbill?

 

You risk losing potential reimbursement by submitting a superbill too late. So, be sure to check on your time limit.

It can typically take health insurance companies around 2-4 weeks to process your superbill. They may pay the full amount of services minus your copay, they may put this amount towards your deductible, or they may deny your claim. If this happens and your superbill is denied, you can contact your insurance company to request information about the denial determination.

To be safe, you may want to make sure you can cover the full cost of your therapy sessions in case your insurance company denies your claim.

 

Want to know more about fees, scheduling, or anything else related to starting therapy?

 

Contact Mend Modern Therapy by email at [email protected].

You can also schedule your free 15 minute consultation here.