How to Get Reimbursed for Therapy
How to make that call as painless as possible.
There are many reasons a psychotherapist might not accept health insurance, and if you are working with us we are considered “out of network,” and you might be scratching your head at how to get reimbursed when working with us.
Getting reimbursed for therapy is a benefit of having health insurance. And while your insurance company might not cover the full amount, they should reimburse a partial amount. Remember that your insurance company sets the reimbursement rate, known as a “contracted rate,” and some companies only reimburse up to their contracted rate.
Lets take two examples of reimbursement looking at two different contracted rates. The first is where an insurance company reimburses less than the therapists billed amount. For example, your therapist might charge $140 for an hour-long session, but your insurance company’s “contracted rate” is $101.23 for a session. They will then reimburse you up to that contracted rate of $101.23.
The second example is when your insurance has a higher contracted rate, which looks like they would pay more than what your therapist bills (but it doesn’t actually work that way). In this example, lets say your therapist charges $140 for an hour-long session and your insurance company’s contracted rate is $143. Your insurance will only reimburse up to the fee that your therapist charges so even though they would pay $143, they will only reimburse you $140 for that session.
Ok, now that you know what a “contracted rate” is, lets use an example of an insurance company that reimburses what your therapist charges. This usually sounds like “[insurance company] reimburses 50% of the fee that your therapist charges.” So if your therapist charges $185 per session, your insurance provider reimburses $92.50.
The Reimbursement Process
Things to Know About Getting a Superbill from Your Therapist.
An “out of network” therapist is a therapist who doesn’t accept your health insurance. You pay your therapist their fee, and your therapist should give you a receipt (proof that you paid) and a superbill (proof of payment with billing codes the insurance company needs). A superbill can also be called a “Statement for Insurance Reimbursement.” You then take that superbill to your insurance company, who will approve or deny reimbursement according to how they operate or provide reimbursement as outlined above.
I always encourage clients to call their insurance company beforehand, so they can financially prepare for what their out-of-pocket costs will be. Below is a list of things to gather before you make that call to make it as painless as possible.
Things to Gather
Your information:
- Name and date of birth
- Primary subscriber name and date of birth
- Insurance ID number
- Group number
- Primary subscriber employer
Your therapist’s information:
- The billing/service CPT code (Common psychotherapy codes are below)
- Ask for verification for these codes/services: 90791 for the initial psychiatric evaluation, 90837 for weekly individual psychotherapy
- Tax ID number: 85-3795897
- NPI number: 1811413933
Things to Ask When you Call Your Insurance Provider
- I’m seeking outpatient mental health/behavioral health benefits in a professional office. Does my healthcare plan cover out-of-network providers for this service?
- If yes, what is my coverage?
- What is my out-of-network deductible? (This is the amount you must pay before the plan begins to cover services. You may have a separate deductible for in-network and out-of-network services)
- How much of my out-of-network deductible has been met so far?
- My therapist charges $150 for CPT code 90837. How much of the $150 will be reimbursed?
- Is there a limit to the number of mental health/behavioral health sessions per year? Per week?
- How can I submit superbills to [my insurance plan] for reimbursement? Is there a time frame in which I need to submit superbills by (for example, within 90 days of receiving a service)
Things to Know About Getting a Superbill From Your Therapist
A therapist who doesn’t accept insurance should automatically provide you with a Superbill after you pay for your therapy services. A reminder that a Superbill is a fancy way of saying “proof of payment with a bunch of things your insurance company needs to reimburse you.” I use Simple Practice and electronic health record & billing software specifically for mental health therapists in private practice, which makes the process seamless for both myself and my clients.
A Superbill has all the required information needed by an insurance provider to reimburse you for services.
This includes:
- Client Diagnosis Code (only the primary code will appear)
- Client Date of birth
- CPT Codes and descriptors
- Dates of service
- Therapist provider ID number, license number, and office location
- The amount charged and payments received
While the time frame varies, its important to submit your superbill as soon as you get it to get reimbursed as quickly as possible. Additionally, some insurance companies only let your submit superbills within 90 days from the date of service.
You can submit your superbill to your insurance company by fax or mail; however, nowadays, most insurance companies have an online portal where you can upload a copy of your superbill (because last I checked, most of us don’t have fax machines lying around our houses).
Once you submit your superbill, you should get reimbursed in 30-90 days. Most will send a check to your home. Sometimes, you can get reimbursement directly to your checking account via direct deposit.
Out of Network Reimbursement Resource for Therapy
If you aren’t interested in jumping through the hoops for out-of-network reimbursement for therapy, you can look into a service that does the reimbursement paperwork for you. With a service like Mentaya, you pay your therapist their full rate, and Mentaya will submit the superbill information on your behalf. On average, they get clients on 70% back on therapy (and no headache of calling/faxing/emailing for you!). After meeting your deductible, you’ll receive reimbursement within weeks! This saves you the time of completing all of the superbill paperwork mentioned above, and it makes it more likely for you to get reimbursement, bringing the cost of therapy much closer to your insurance copay.
Appeal if Your Insurance Denies your Therapy!
So you went through the process above and got a big “nope” from your insurance company. Before you get totally discouraged, lets review common reasons an insurance company might deny your reimbursement request. You can find this on your “Explanation of Benefits” or EOB statement. If you don’t understand why your request for reimbursement was denied, or you cant see a reason it was denied, call the insurance company and ask for a clear reason it was denied.
- Typos. Ugh, annoying, but double-check that your name, therapists name, billing codes, and your therapist NPI and ID number are all correct (Ive had a claim denied when a zip codes last two digits were reversed so double-check!)
- Filed “not in a timely manner.” This usually means you waited too long to submit your superbill. You might not be able to appeal it, but use this as a reminder to send your superbill in ASAP next time.
- “Not Medically Necessary” This can happen if an insurance company says your diagnosis doesn’t line up with the type of treatment your therapist provides. Call and ask for more information, and then ask your therapist to write a letter or call your insurance company explaining how their treatment fits your diagnosis
There are two main laws or policies to help protect mental and behavioral health care in the U.S. The Parity Act (MHPAEA) and the Affordable Care Act (ACA). The MHPAEA mandates healthcare plans to cover mental health care at parity, or “equally,” with other forms of medical care. This protects patients because insurance companies are not allowed to limit mental health care in ways they don’t limit other types of health care. Think: if an insurance plan covers occupational therapy for 20 sessions, they have to cover behavioral therapy for 20 sessions. The ACA requires behavioral and mental health coverage in their health plans. They call it “an essential benefit.”
On the EOB letter, there should always be an “appeals” section. This might involve a phone call or sending back a form with amended or updated information. Generally, you’ll have 90-180 days to file an appeal. If you need help from your therapist, a partner, or a friend, you have some time to ask.
We have partnered with Mentaya to help clients use their out-of-network benefits to save money on therapy. Use this tool below to see if you qualify for reimbursement for my services.