How to Use Out-of-Network Benefits for Therapy in New York and New Jersey

An in-network therapist has a contract with your insurance company and bills them directly; you typically pay a copay or coinsurance. An out-of-network therapist has no contract with your plan, so you usually pay for the session up front and then submit a claim to your insurer for partial reimbursement.

Before assuming you need to go out of network, check whether your plan is one I am in-network with. You can find the current list on the Fees & Insurance page. Coverage depends on your specific plan and state, so it is always worth verifying.

Three terms shape how much you will get back: your deductible, your coinsurance, and the allowed amount. Knowing these before you start makes reimbursement far less surprising.

• Deductible: the amount you pay out of pocket each plan year before your insurer starts reimbursing. Out-of-network deductibles are often separate from in-network ones.
• Coinsurance: the share of the cost your plan pays after the deductible is met, expressed as a percentage. The percentage varies widely between plans.
• Allowed amount: the amount your insurer considers reasonable for a service. Reimbursement is usually calculated from this figure, which may be lower than the session fee.
• Out-of-pocket maximum: the most you pay in a plan year. Once reached, your plan may cover more of the cost.

Call the member services number on your insurance card and ask about outpatient mental health benefits for out-of-network providers. Write down the date, the name of the person you speak with, and a reference number for the call. These questions cover the essentials:

• Do I have out-of-network coverage?
• If so, is there an annual deductible? Have I met it? If not, how much has been met?
• What percentage do you cover for out-of-network mental health providers?
• Is there a maximum amount you reimburse per visit or per year?
• Is there a claim form that I must use to submit for reimbursement?
• How much time do I have to submit a claim after my session?
• Do I need a pre-authorization? If so, how do I obtain it?

You may be asked for the type of provider (a licensed mental health counselor or licensed professional counselor) and the service codes described below.

A superbill is a detailed receipt that includes everything your insurer needs to process an out-of-network claim: provider information, dates of service, service codes, diagnosis codes, and the amount paid. You submit it to your insurer, and they reimburse you directly according to your plan.

For out-of-network clients, I provide superbills and help with the reimbursement process. Some people submit after every session; others prefer to submit monthly. Either works, as long as you stay within your plan's filing deadline.

CPT (Current Procedural Terminology) codes describe the service you received. Insurers may ask about them when you call, and they appear on your superbill. The most common codes in my practice are:

• 90791: initial consultation (intake session)
• 90834: 45-minute psychotherapy session
• 90837: 53-minute psychotherapy session

Reimbursement can differ by code, so it is worth asking your insurer about each one.

Timelines vary by insurer and by how you submit. Online portals are often faster than mailed claims. Your plan will also have a deadline for submitting claims after a session, so ask about it when you call and keep it on your calendar.

If a claim is denied or reimbursed at a lower amount than expected, call your insurer and ask why. Common causes are a missing pre-authorization, a deductible that has not been met, or a missing piece of information. Many issues can be resolved with a quick correction and resubmission.

Good records make out-of-network benefits much easier to use. A simple folder or spreadsheet is enough.

• Save every superbill and the date you submitted it.
• Keep each Explanation of Benefits (EOB) your insurer sends.
• Note call dates, representative names, and reference numbers.
• Track how much of your deductible has been met during the year.

If out-of-network benefits are limited, there are other options. A sliding scale is available based on an eligibility application. Some people also use a health savings account (HSA) or flexible spending account (FSA) for therapy costs; check with your plan administrator. Accepted payment methods include Visa, Mastercard, American Express, Discover, and cash.

Questions about cost should never be the reason you put off getting support. In a free 15-minute phone or video consultation, we can talk about what you are looking for and go over insurance and payment options together. I see clients by secure video across New York and New Jersey. Request a free consultation.