Back to Blog

How to get Reimbursed by your Insurance

Questions and answers to get your insurance to pay you.

Things to know:

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 paying or reimbursing for services. You'll need to check online or call your insurance to see what amount you have already met.
  
  Note: not all health insurance deductibles reset on January 1st. Make sure you know what date your deductible resets as it may be a different month than you expect.

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

• If you have a co-pay, you will pay the flat rate stated in your insurance plan. Co-pays vary by insurance but are typically anywhere from $15 - $50 for therapy.
• Sometimes your insurance may say you have "coinsurance" instead of a co-pay. This means your plan may cover a specific percentage of the allowed amount insurances will pay for specific services.
  Example: Your insurance pays $100 for 1 hour of therapy (CPT 90837) and you have a 20% coinsurance after your deductible has been met. This means that once your deductible has been met, insurance will pay $80 and you will pay $20 per 1 hour session.
  
  If your therapists takes your insurance, they should know their contracted amount to charge per specific services. They should be able to tell you what amount you will be paying for your coinsurance based on services they provide. It never hurts to check with your insurance yourself as well.
  
  If your therapist does not take your insurance, you may still be able to get out of network benefits from submitting a superbill.  Note: Out-of-network coinsurance usually costs you more than in-network coinsurance. You will likely need to call your insurance to learn more about your out-of-network benefits. To make this easier, you can reference these CPT codes (billing codes) that are commonly used by therapists to bill insurance for our services when you are asking about this:
  CPT 90832 (16-37 minutes of psychotherapy)
  CPT 90834 (38-52 minutes of psychotherapy)
  CPT 90837 (53+ minutes of psychotherapy)
  CPT 90853 (Group psychotherapy)
  
  Please note that I typically aim to see clients for 55 minutes, meaning I typically bill CPT 90837. 

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 $180 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 $102 ($180, 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?

• First, make sure your therapists can provide a superbill. A superbill is a detailed, itemized receipt of services provided by a therapist who is out-of-network. 
• Once you get your superbill, you can submit it to your insurance and wait for reimbursement. Your therapist does not submit a superbill for you.

• You will need to talk to your insurance their process for submitting superbills: 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?

• Ask your insurance 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), so make sure when you ask your insurance about their reimbursement rates that you are specifying what kind of professional you are seeing.