What is out of network reimbursement?

In a nutshell, Out of Network Reimbursement is when a person with insurance pays upfront for medical services from someone not contracted with the insurance company, and the insurance then pays the person back.

What is an example of out of network reimbursement?

Say you decided to visit a medical doctor recommended by your friend, but this doctor does not accept your insurance. You can still see this doctor, but you will pay their fee upfront. This doctor will then give you an itemized receipt of the services provided, and you then submit a claim to your insurance to get what you paid that doctor reimbursed. This itemized receipt is called a Superbill.

How to find out if your insurance includes out of network services:

● Call the member services or customer service number located on the back of you insurance card.

● Select the option about benefits and/or eligibility and speak with a benefits representative.

● They will then tell you what your benefits are. Either write those down or ask the representative to send you a link that outlines all your benefits. If you do not have any out-of-network benefits, you will generally not be able to be reimbursed for the services.

● When speaking to a live person, state that you are “looking to see an out-of- network provider” for “outpatient psychotherapy” and want to know your “out-of-network benefits for psychotherapeutic services”. You are not looking for inpatient services or medical services.

Questions to ask about reimbursement:

Is a diagnosis required for reimbursement?

Do they cover psychotherapy via telehealth?

Are mental health services provided by a Licensed Clinical Professional Counselor or Licensed Professional Counselors covered by your insurance? (LCPC, CPC, PLCP)?

About licensed providers:

You’ll need to ensure that the provider you’re asking about is licensed to work in the State where you live.

Mental Health Professional License providers include:

  • Licensed Clinical Professional Counselors / Licensed Professional Counselors
  • Licensed Mental Health Counselors
  • Licensed Clinical Social Workers
  • Marriage and Family Therapists

How much will you be reimbursed? Is there a deductible? Write this information down.

Is there a maximum out-of-pocket limit and if so, once you reach that, what is the reimbursable amount and will they cover 100% after you reach that?

Is any prior authorization, pre-certification, or approvals needed? Who needs to make these (your primary care physician, psychiatrist?)

● Is there a visit limit?

Are the following codes covered?
  • 90834 Individual psychotherapy
  • 90837 Individual psychotherapy
  • 90847: Couples therapy

● How will you get reimbursed? Do you need any special forms? Do you submit by paper, online?

● Within how many days after the date of service do you need to submit.

● Tell them you will be paying the provider up front and ask them how you make sure that

● Payment does not go to the provider. The insurance makes the payment directly to you.

  • Does your insurance cover telehealth services? Is there a specific telehealth platform that must be used for therapy? Some insurance companies changed their policy after the pandemic and are no longer covering Telehealth for Out Of Network benefits, or they want providers to use a certain Telehealth platform that requires contracting.
More Tips for Reimbursement

Please note that every insurance company is different and the following are only tips. If you are having difficulties, the best person to contact is a customer service representative of your health insurance company:

  • Have a pen and paper handy. Always write down the number you called, the name(s) of the person/people you spoke to, the date, start time, and end time of the call, and relevant notes of the call. Usually there is a reference numbers or case numbers. Make sure to write these down.
  • If there is something you don’t understand, ask the representative to clarify it for you. However, remember that the system is sometimes complicated and confusing, and the customer service representatives are doing their best to provide the information.
  • Generally there is a form you need to submit for reimbursement. Its a good idea review this form first. This way, you have all the details to quickly complete the form and process your reimbursement.
  • Some insurance companies will try to encourage you to use an in-network provider before giving you information. Should you wish to proceed with an in-network provider, the insurance company will provide you with a current list of providers.
  • Out of Network (OON) benefits are typically part of insurance plans. Generally you should not have to provide details about why you want to use your OON benefits.
  • If you feel the representative does not know how to help you, or is withholding benefit information, you can ask to speak to another representative.
  • If applicable, ask the representative how much of your deductible has been met to date and what date does the deductible start/end. Usually insurance coverage runs from January 1st to December 31.
  • Ensure that the insurance company will not require any documentation from your provider.