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Using Out-of-Network Benefits

1. Check your out-of-network (OON) benefits with your insurer

These are found in the Summary of Benefits included in a member information packet or on the 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 any reimbursement.

Coinsurance: This is the percentage of the service fee that you’re ultimately responsible for paying, even after meeting the deductible.

Allowed amount: This is a cap on the session fee set by the insurance company.

If your out-of-network deductible is $1,000, and your insurance company pays for 100% of services after you meet that amount, you’ll have to pay $1,000 out of pocket, and after that some amount of your out-of-pocket expenses will be reimbursed to you in the form of a check (mailed to you after you submit your claim).

Insurance companies determine an allowed amount which caps their coverage of session. If your insurance has determined $100 is their “allowed amount” per session, at a 25% coinsurance rate, your insurance company will still only reimburse you up to $75, no matter what the therapist’s session fees are.  You are responsible for the full session fee, regardless of your insurance company's allowed amount.

2. Call your insurance company to verify your benefits

Ask these questions when speaking to your insurance company about benefits:

• What is my out-of-network deductible for outpatient mental health? (Outpatient means treatment outside a hospital.)

• How much of my OON deductible has been met this year?

• 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.

This document will include a diagnosis, session dates, and charges, as well as all identifying information the insurance company needs.  Additionally, your insurance company may request full records at any time.