How to Check Your Out-of-Network Benefits (a 5-Minute Phone Script)

If you have a PPO insurance plan, there's a decent chance your plan will pay you back for a chunk of every therapy session, even at a private-pay practice like ours. Most people never find out, because checking means calling your insurance company, and calling your insurance company sounds about as fun as a root canal during a toddler meltdown.

So we made it easy. Grab your insurance card, block off five minutes, and read the questions below word for word. That's it. No jargon knowledge needed; the translation table at the bottom covers anything they say back to you.

Call the Member Services number on the back of your insurance card. When the phone tree asks what you need, say "benefits." When you reach a human, say:

Write down the answers; you'll want them later.

1. "Do I have out-of-network benefits for outpatient mental health?" If the answer is no, you're done (a short call). If yes, keep going.
2. "What is my out-of-network deductible, and how much of it have I met this year?"
3. "After my deductible, what percentage do you reimburse for CPT code 90837?" (That's the standard code for an individual therapy session. For an intake, you can also ask about 90791.)
4. "What is the allowed amount for 90837 in my area?" This is the number your reimbursement percentage is based on.
5. "Do I need a referral or preauthorization for outpatient mental health?" Usually no, but it's a 5-second question that prevents surprises.
6. "How do I submit a superbill, and how long does reimbursement take?" Most plans have an online portal; some still love a fax machine. (Yes, fax machines still exist. We were surprised too.)

Here's a realistic example. Say your session fee is $170, your plan's allowed amount is $150, and your plan reimburses 70% after your deductible is met. That's $105 back per session, bringing your real cost to about $65. Your numbers will vary, but this is why the five-minute phone call is worth it: for many families, out-of-network therapy costs far less than they assumed.

• Deductible: the amount you pay out of pocket each year before your plan starts chipping in. Resets every January, usually right when you least expect it.
• Coinsurance: the percentage split after your deductible. "70% coinsurance" means they pay 70%, you pay 30%.
• Allowed amount: the price your insurance company has decided a therapy session "should" cost. Your reimbursement percentage applies to this number, not necessarily the full session fee.
• Superbill: an itemized receipt we give you monthly with every code your insurance company needs. You submit it; they reimburse you directly. You don't have to create anything yourself.
• CPT code: the billing code for a type of service. 90837 is an individual therapy session; 90791 is an intake.

Services like Mentaya and Thrizer can check your benefits and submit superbills for you, usually for a small fee. And if you'd rather just talk it through with a human who isn't reading from an insurance script, that's what our free 15-minute consultation is for. Bring your questions and we'll sort out your options together.

For our current rates and how superbills work at our practice, see the Cost page. Curious why we're private pay in the first place? That story is right here.