Navigating health insurance reimbursement

Insurance

I am an out-of-network therapist. That means you will pay for counseling out-of-pocket at the time of service. Your insurance provider may reimburse you completely or for a portion of your health care expenses. I have provided you a list of questions and key terms to help you navigate understanding your insurance plan.

Want to find out if your insurance provider will reimburse you for counseling services?

Your health insurance card will have customer service contact information on the back of the card. Call the number listed for member services or mental health. Follow the questions provided on this page and write down the answers you receive. Keep a copy for future reference and reimbursement requests. Ask for explanations of anything you do not understand.

Questions to ask your insurance company

 

  • Does my policy cover out-of-network Licensed Clinical Professional Counselors? My therapist is licensed in the State of Illinois.

  • What is my out-of-network deductible?

  • What is the Allowed Amount of Fee and what percentage of the Allowed Amount will be reimbursed?

  • After a counseling session, how long do I have to submit my request in order to be considered for reimbursement?

  • My therapist is willing to provide me a Superbill, which includes my therapist’s NPI and EIN numbers, session dates, CPT code, diagnosis, and fees. Do you need additional information?

  • How do I submit for reimbursement? What is the web or mailing address?

  • What is the payment schedule? That is, how long does it take for you to process my paperwork and reimburse me?

  • What is the claims department contact information so that I can follow up on my claim?

Before you make the call

Language used within any industry can be confusing for anyone outside of that industry. The terms and descriptions below are commonly used by insurance providers. Understanding these terms will be helpful for accurately knowing your unique insurance plan and coverage.

Key terms

Out-of-Network

An out-of-network healthcare provider does not have an existing contract with your insurance company. However, many plans allow for some financial reimbursement for services received  by out-of-network counselors.

HMO

Health Maintenance Organizations typically direct healthcare through your primary care physician, who will either address your concern through treatment or refer you to an in-network provider. Most HMO plans do not cover out-of-network care. However, check with your insurance provider to see if your plan will cover out-of-network mental health counseling.

PPO

Preferred Provider Organizations contract with independent service providers. This means you can see a specialist without a referral from your primary care physician. If you have a PPO, you are most likely eligible to seek out-of-network service reimbursement.

Superbill

A Superbill is an itemized receipt of therapy services provided. Your insurance company requires such information for reimbursement. I provide Superbills at the end of each month, unless requested otherwise.

Deductible

A deductible is the amount of money you must pay for healthcare before your insurance begins to pay.

OON Deductible

An out-of-network deductible is the amount of money you have to pay before your insurance provider will reimburse you.

Co-pay

A co-pay is a fixed dollar amount that you are responsible to pay at the time your healthcare service is received.

Co-insurance

Co-insurance is the percentage of service fee you owe, beyond what is covered by your insurance provider.