How to Use Out of Network Insurance Benefits

 
 
 

So you’ve found a great therapist but they’re “Out of Network” (OON) with your insurance company.  Hang tight - we’ll explain what this means and provide detailed instructions for using your out of network benefits. 

TL;DR simplified steps:

  1. Contact your insurance company to see if you have OON benefits. If so, ask for:

    1. Your OON deductible

    2. Your coinsurance/their reimbursement rate

    3. The allowed amount for the type of therapy service you receive

  2. Pay for therapy sessions up front

  3. Get a superbill (receipt) from your therapist

  4. Submit this superbill to your insurance company

  5. Wait patiently

  6. Get a reimbursement check in the mail! (And review the paperwork to calculate your exact net cost)

What does Out of Network mean?

Out of Network (OON) is a designation for therapists and other health providers who aren’t contracted with insurance companies, but who can provide you with itemized receipts (called “superbills”) that you can submit to your insurance company for potential reimbursement*.  

In order to do this, you pay the full session cost upfront directly to your therapist, receive your receipt/superbill, submit it to your insurance company, and get a check in the mail with your reimbursement (more detailed instructions below). 

Note: some therapists are self-pay only and do not provide superbills, so it’s best to ask them directly if you’re unclear.

*What do you mean, “potential reimbursement”?

In order to receive reimbursement from your insurance company, you need to have a few things:

  • You need to be actively enrolled in a health insurance plan

  • You need to have OON benefits on that insurance plan

  • Those OON benefits need to cover therapy services (usually called “outpatient behavioral health” or “outpatient mental health” in the insurance world). 

  • You need to reach your “OON deductible” (more on this below). 

How do I know if I have OON benefits?

You have two options for finding out if you have OON benefits. 

Option 1: by phone (suggested)

  1. Grab your insurance card.

  2. Call the customer service phone number on the back of the card.

  3. Follow instructions for accessing an “Explanation of Benefits (EOB)” or similar prompts to check your coverage. 

  4. If you connect to a human, keep them on the line and go to the next step to ask them about additional information you need. 

Option 2: online (not always available)

  1. Log into your online insurance portal. 

  2. Search for your “Explanation of Benefits (EOB)” or a similar page that outlines in-network and out-of network coverage. 

Okay, I have OON benefits!  Now what exactly do I need to know about my coverage?

Here’s what you can ask the insurance representative (or search on your EOB if you’re using the online option). 

  • What is my OON individual deductible? This is the amount you have to pay out of pocket before you start getting reimbursed.

    If my deductible is $500, I have to pay $500 out of pocket first. Once I’ve paid $500, whatever I spend after that is eligible for reimbursement. 

  • What is my co-insurance and the insurance company’s reimbursement rate? With OON benefits, you’re splitting the cost of therapy with your insurance company.  The co-insurance is the percentage you pay, and the reimbursement rate is the percentage they pay. 

    Their reimbursement rate is 60% per session, so my co-insurance is 40%.

  • What is the allowed amount* for an outpatient therapy session?  Okay - this might be the most confusing part, so read carefully.  Insurance companies decide how much your therapy sessions “should” cost, and probably to no surprise, they price this much lower than the actual market rate so they can limit how much they reimburse you.  

    In my experience, most insurance companies will not give you this number over the phone and they can change it without notice.  The primary way you can find out your allowed amount is to submit a claim and review the itemized document they send back to you. 

    TIP: therapy sessions have certain insurance codes (“CPT code”), so you can try giving them the code and see if they’ll tell you the allowed amount. The code for a 45-minute therapy session is 90834 and a 55/60-minute therapy code is 90837.

    So what does this mean for your pocket?  

    • It affects how long it takes to reach your OON deductible. Only the allowed amount of what you pay out of pocket will be applied to your deductible.  

    • The reimbursement rate only applies to the allowed amount.

    - Let’s walk through an example.  Your therapist charges $200 for each therapy session.  Your out of network deductible is $400.  The reimbursement rate is 80% and your co-insurance is 20%.  The allowed amount per therapy session is $100.

    - You will have to pay $400 out of pocket to reach your deductible, but remember - they only count the allowed amount ($100).  

    - For each $200 therapy session, $100 will be put towards your deductible.  So you will have to attend four therapy sessions and pay $800 out of pocket in order to reach your $400 deductible.

    - Once you reach your deductible, you will pay $200 for each session up front, and your insurance company will reimburse 80% of the allowed amount, which is $100.  

    - So they’ll reimburse you $80 for every $200 therapy session, making your net cost $120. 

Got it. So how do I submit a claim to get some money back?

  • Ask your therapist when they’ll give you a superbill (usually this happens monthly).

  • Once you get your superbill, log on to your insurance company’s website and search for somewhere to “submit claims”.  For BCBS, you submit them through the messaging tab

  • Upload your superbill + click submit

  • Patiently wait :)  It can take anywhere from 2 weeks to 2 months to get reimbursed, assuming there are no issues with the info you provided. 

Questions? Reach out, we can help. We can explain your unique benefits and can call your insurance company on your behalf if you get stumped.

Grace Dickman