1. Check your out-of-network benefits
These can typically be found in the Summary of Benefits, included in a member information packet or on your insurance company website. Keep an eye out for these terms:
Out-of-network deductible: This is the amount of money you have to pay before you are eligible for reimbursement.
Let’s say your out-of-network deductible is $1,000, and your insurance company pays for 100% of services after you meet that amount. That means you’ll have to pay $1,000 out of pocket, after which you’ll have “met your deductible.”
In this scenario, if you spend $2,500 on services, you’ll have to pay $1,000 out of pocket, but a portion of the remaining $1,500 will be reimbursed to you in the form of a check (mailed to you after you submit your claim). Deductibles reset every calendar year, and any health expense you pay out-of-pocket contributes to meeting it.
Coinsurance: This is the percentage of the service fee that you’re ultimately responsible for paying.
If the evaluation costs $2,500 and your coinsurance is 25%, you are responsible for paying $625. Just remember that this comes in the form of a reimbursement: you’ll need to pay the full $2,500 upfront, then your insurance will send you a check for $1,875 , once you have met the deductible and submitted a claim.
Some insurance companies determine an “allowed amount,” which caps the evaluation fee that they will cover. If your insurance has determined $1,500 is their “allowed amount” per session, at a 25% coinsurance rate, your insurance company will still only reimburse you up to $1,500, no matter what the evaluation fees are. In other words, if your insurance has an allowed amount of $1,500 but your evaluation fee is $1875, you will not get reimbursed more; you will still be reimbursed $1,500, and will be ultimately responsible for $1,000.
2. Call your insurance company to verify your benefits
The best way to be sure of your benefits is to clarify with your insurance company member services line. You can find this phone number on the back of your insurance card or through your online insurance platform.
Ask these questions when speaking to your insurance company about benefits:
How much of my deductible has been met this year?
What is my out-of-network deductible for outpatient mental health services? (Outpatient means treatment outside a hospital.)
What is my out-of-network coinsurance for outpatient mental health?
Do I need a referral from an in-network provider to see someone out-of-network?
How do I submit claim forms for reimbursement? (Claims are forms that are sent to your insurance company to receive reimbursement for sessions you paid for out of pocket.)
3. Ask your provider for a Superbill
After making your payment you can ask your provider for a document called a Superbill. This document will include the codes and fees for services rendered and should be sent directly to your insurance company in order to receive reimbursement.