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How to get Reimbursed by your Insurance

Questions and answers to get your insurance to pay you.

Do I have out-of-network benefits for mental health/behavioral health services?

• Not all plans cover out-of-network care. Ask if your plan includes coverage for therapy with providers who are not in your insurance network.

What is my deductible for out-of-network services, and how much of it have I already met?

• The deductible is the amount you must pay out-of-pocket before your insurance begins reimbursing.

After I meet the deductible, what percentage of the session fee will be reimbursed?

• This is sometimes called “coinsurance.” For example, your plan may cover 60% of the allowed amount, and you would be responsible for the remaining 40%.

What is the “allowed amount” or “reasonable and customary fee” for therapy sessions?

• Insurance often reimburses based on their own set fee, not the full fee charged by the therapist. For example, my fee is currently $150 but your insurance may only have an “allowed amount” for therapy with an LMHC of $130. That means that if your plan covers 60% of out of network claims, they would pay you $78 / session (60% of $130, the allowed amount) and you would pay $72 ($150, my session fee, minus the $78 insurance pays).

Do I need a referral or prior authorization for out-of-network therapy?

• Some plans require approval from your primary care provider or from the insurance company before covering services.

How do I submit claims for reimbursement?

• Ask about the process: what forms are needed, whether claims can be submitted online, and how long reimbursement typically takes.

Are there limits on the number of sessions covered?

• Find out if your plan caps the number of therapy visits per year (or per diagnosis).

 Do you reimburse for telehealth with out-of-network providers?

• Some plans cover telehealth the same way as in-person visits; others may not.

Are there different coverage levels for different types of therapists?

• Some plans differentiate between psychologists, clinical social workers, marriage and family therapists, and counselors (LMHCs in Washington, which is what I am).