Here are some tips for speaking with your insurer to find out about out-of-network mental healthcare coverage:

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#1: You will want to find your insurance provider's "behavioral health" line or "member services" line. Both phone numbers are typically found on your insurance card or on the website for your insurance. You can also use a search engine to find these numbers.

 

#2: Call that number and ask your health insurance provider the following questions:

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• "Do I have 'out of network coverage' for mental or behavioral health services? Will you accept a superbill from an out of network therapist?"

  • (if no, this means they will most likely not reimburse for our sessions).​

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#3: If they say yes, they do reimburse for out-of-network therapists, then you may want to follow up with these questions:

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• "Are there any limitations that would cause you to *not* reimburse me for a session with an out-of-network therapist?"

  • Some insurers may have added requirements that would hinder your ability to get reimbursed.

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• "Are there any steps required to authorize coverage of therapy sessions?"

  • Some insurance companies will require that an in-network provider, such as your primary care physician or psychiatrist, provide an authorization or referral stating your medical necessity for services. Sometimes this authorization may need to be renewed on a regular basis (often every 3-6 months). 

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• "What steps are required to submit a superbill, and how long does it typically take to receive reimbursement?"

  • This will give you information about how to submit the superbills your therapist gives you to your insurance company for reimbursement. They can also give you a sense of how long you will have to wait between paying upfront for therapy and getting reimbursed by your insurance.
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• "How much will I be reimbursed for each session?"

  • Some insurance plans will give you partial reimbursement, while others will fully reimburse you. 

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• How soon after a session must a superbill be submitted?"

  • Often insurance companies will have time limits on submitting superbills.  This varies by company but is typically between 2-6 months after your session with a therapist.

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• "How high is my deductible and have I met it yet?"

  • (this tells you how much you will need to spend out of pocket before your sessions are able to be reimbursed by insurance).

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• "What is my required copay/coinsurance?"

  • In other words, what percentage of the cost are you required to cover yourself, and what percentage will your insurance cover? (This will help you determine whether you will receive partial or full reimbursement).

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• If your insurance does not reimburse for superbills with out-of-network providers, you may still be able to do what is called a "Single Case Agreement". While I don't personally do single case agreements at the moment, many therapists do. You can ask your insurance the following questions to find out more:

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• "Do you make 'single-case agreements' and what is the process for establishing a single-case-agreement?

  • Some insurance providers who don't usually cover out-of-network providers will still cover certain services under a "single-case-agreement". Typically this is justified when the outside therapist has a clinical specialization that is not available among their in-network providers. 

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#4: When speaking with your insurance company, you may be required to provide certain information including therapist credentials, therapist zip code, and CPT codes.
 

• My therapist credentials are: Myles Marcotte, registered Licensed Clinical Social Worker, #122838

• My NPI number is: 1992219224

• The practice address is: (Please email me to request this)

• The practice phone number is: 562-265-8486

• The CPT codes I use are as follows: 90791 (for your first appointment) and 90834 (for ongoing individual appointments).

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I know this can be an overwhelming process. I hope this guide helps you to navigate your insurance provider!