Using Your Out-of-Network Benefits
Understanding what your insurance may cover, even when I'm not in your network.
I don't take insurance directly, and I know that's one of the first things people want to understand before deciding whether working together is feasible. The good news is that many clients are able to get partial reimbursement through their out-of-network benefits, and the process is more straightforward than it might look at first.
This page walks you through how it works, what to expect, and how to find out what your specific plan covers.
What 'Out of Network' Actually Means
Being out of network simply means I haven't contracted with your insurance company to accept their set rates. It does not mean your insurance won't help cover the cost. Many plans (particularly PPO plans) include out-of-network benefits that allow you to see providers outside their network and still get reimbursed for a portion of what you paid.
HMO plans are different. Most HMO plans don't include out-of-network benefits, which means reimbursement may not be available. If you have an HMO and are seeking a specialized type of therapy not available through your network, it's worth asking your insurance company about an exception that some plans will grant called a single case agreement. I'd encourage you to call the member services number on the back of your insurance card and ask directly.
If you're not sure what kind of plan you have, the benefits checker on this page can give you a quick answer.
Check Your Benefits First
Before we begin working together, it can be helpful to check out the Mentaya benefits checker here. It takes about thirty seconds and will tell you whether your plan includes out-of-network mental health benefits and give you a sense of what reimbursement might look like.
A few things worth knowing before you check:
Your plan may have a deductible that needs to be met before reimbursement kicks in. Costs for other other out-of-network services you’ve already used this year may have already counted toward it.
Once your deductible is met, your plan will typically reimburse a percentage of what's called the 'allowed amount', which is the maximum your insurance considers reasonable for the service. This is usually somewhere between $150 and $200 for a therapy session, depending on your plan and location, regardless of what you actually paid.
Reimbursement is paid directly to you, not to me. You pay my fee at the time of our session, and any reimbursement from your insurance comes back to you separately.
How the Superbill Process Works
After each session, I provide a detailed receipt that includes everything your insurance needs to process a claim: my license information, the date of service, the billing code for the session, and your diagnosis code. This is the superbill.
You submit that superbill to your insurance company, and they reimburse you based on your plan's out-of-network benefits. Most insurance companies allow you to submit online through their member portal, by mail, or by fax.
The billing code for individual therapy sessions is 90837, which covers sessions of 53 minutes or more. This is the standard code for therapy sessions and the one your insurance will be expecting.
A note on therapy intensives:
Intensive sessions run longer than a standard therapy hour, but insurance reimbursement is currently capped at the 60-minute billing code regardless of session length. This means your superbill will reflect one session at the 60-minute rate per day of treatment, even if we worked together for several hours. You won't be reimbursed for the full length of an intensive, but you will be reimbursed for something. For sessions that happen on separate days, each day can be submitted separately.
What to Realistically Expect
Your reimbursement will be a percentage of your insurance company's allowed amount, not a percentage of my fee. So if your plan covers 60% of out-of-network costs and the allowed amount is $180, you'd receive $108 back per session, regardless of what my actual rate is.
If you haven't met your deductible yet, the early sessions will go toward meeting it rather than generating reimbursement. Once you've met your deductible, reimbursement kicks in automatically for subsequent sessions. If you're starting therapy partway through the year, it's worth considering whether you've already made a dent in your deductible through other health spending.
Insurance reimbursement rates can also shift over time, sometimes without clear explanation. You may find it useful to treat any estimate from your benefits check as a starting point rather than a guarantee, and to call your insurance company to confirm your specific benefits before we begin.
Questions Worth Asking Your Insurance Company
When you call the member services number on the back of your card, these are the questions that will give you the clearest picture:
Do I have out-of-network mental health benefits?
What is my out-of-network deductible, and how much of it have I already met this year?
What percentage of the allowed amount will you reimburse after the deductible is met?
How do I submit an out-of-network claim?
Is there a filing deadline for submitting claims?
Having the answers to these before our first session will give you a much clearer sense of what to expect financially.
If You Have More Questions
I'm happy to answer questions about how this works in the context of our work together. If you're trying to figure out whether working with me is financially feasible, that's a completely reasonable thing to want clarity on before committing, and I'd rather you have that clarity upfront.
You can also reach out to your insurance company directly using the member services number on the back of your card. They're required to walk you through your benefits, so it’s worth making the call even if it feels like a hassle.