Navigating Out-of-Network Benefits to Pay for Therapy: A Comprehensive Guide
Finding the right therapist can be a challenging journey, especially when you’re restricted by the list of in-network providers your insurance company offers. Often, the best fit for your mental health needs might be an out-of-network therapist. Fortunately, many insurance plans offer out-of-network benefits that can help cover the cost of these sessions. Understanding how to navigate these benefits and make use of tools like superbills can significantly ease the financial burden of therapy.
Out-of-network benefits are a feature of some insurance plans that allow you to see providers who are not within your insurance network. Here's a basic outline of how out-of-network benefits work:
With out-of-network benefits, you usually pay the therapist up front and then submit a claim to your insurance company for reimbursement. This reimbursement is based on your plan’s allowed amount for out-of-network services, which might be less than what your therapist charges. Most individuals are reimbursed between 60-80% of their session fee, leaving an out-of-pocket amount that is similar in cost to a co-pay.
A Superbill is a detailed invoice provided by your therapist that you can submit to your insurance company for reimbursement. Unlike regular receipts, superbills include comprehensive information required by insurance companies to process out-of-network claims. Here’s what typically appears on a superbill:
Provider Information: Name, address, and contact information of your therapist.
Client Information: Your name, address, and insurance details.
Session Details: Dates of service, duration of sessions, and a description of the services provided (often using CPT codes).
Fees Charged: The amount charged for each session.
So how do you find out if you have out of network benefits, and how to start using them? Before starting therapy, review your insurance plan’s summary of benefits. Look for information on out-of-network mental health coverage, deductibles, reimbursement rates, and any annual limits on coverage.
Ensure your therapist is willing to provide a superbill. Most licensed therapists are familiar with this process and can help you understand the information they’ll include. At Prism, we provide a Superbill that goes directly to your email every month!
To submit a claim, collect your superbills and submit them to your insurance company. Some insurers have online portals for this purpose, while others may require you to mail in physical copies. It’s important to note that insurance companies can be slow or sometimes make errors in processing claims. Follow up on your submissions to ensure that you receive the appropriate reimbursement. Keep a record of all communication and documentation in case you need to appeal a denied claim.
