Insurance and Services: Understanding Out-of-Network Coverage

Navigating the insurance world can be complicated. You’ve found a provider who feels like a good fit, but they don’t accept your insurance. So what do you do next?

Let’s break down some key terms.

In-network (INN) provider: a provider who is paneled with your insurance company and bills the insurance company directly. When you work with an in-network provider, you pay a co-pay to the therapist, and they take care of the rest.

Out-of-network (OON) provider: a provider who is not paneled with your insurance company and cannot submit claims on your behalf. When working with an OON provider, you will pay the provider directly, and then submit the claim yourself to your insurance company for any potential reimbursement. If eligible, the insurance company will send a check for reimbursement directly to you.

Superbill: A superbill is a summary of the services provided which is given to you by the provider. One you have this, you submit it directly to the insurance company. Insurance companies will not accept standard invoices as proof of service. The superbill contains all the providers necessary information (license number, NPI, Tax ID) and the information regarding your service (session type, length of session, location of session, and diagnosis).

Do I have reimbursement potential?

Check your insurance card

Some insurance cards have this information printed right on the front of the card. If so, it will state both the in-network and the out-of-network deductible costs. If your card does not have any OON information printed on it, you will have to check your client portal with the insurance company, or call them directly.

Call your insurance company

To check coverage over the phone, call the customer service number on the back of your insurance card. You will listen to the prompts and select the option to review benefits and eligibility. Once connected to a customer service representative, you will ask them the following questions:

  • Do I have out-of-network coverage for outpatient mental health services with a licensed and board certified psychiatric-mental health nurse practitioner for the following CPT codes?

    • 99205

    • 99214

    • 99213

    • 90833

  • Is there an out-of-network deductible?

  • What percentage will I be reimbursed?

  • Is there a pre-authorization required?

  • How do I go about submitting a claim?

It is helpful to record the name of the representative and ask for a reference number for the phone call.