“In-Network” Mental Health Benefits
(What to Ask Your Insurance Company if it is not the Student Health Benefit Plan)
- Call the Mental Health number on your insurance card. Say that you want to access your benefits for Outpatient Psychotherapy with an in-network provider.
- If you want to be sure the therapist you wish to see is in your network, give the insurance representative the provider’s name and address. They might also ask for the therapist’s NPI number, which you can request from the provider. Be sure you have the proper spelling for the provider as you seek verification that they are indeed, in-network.
- If the provider is in your network you may be given an authorization/precertification code covering an initial session and several follow up appointments. WRITE this number down, including what is covered and the effective dates (for example, they might authorize 6 appointments to be completed within 90 days.)
- Verify your copayment. Usually it is the “specialist” copay listed on your card. Occasionally there are more details about the copay.
- Find out if you have any limit on the number of visits per year, and if so, are visits with a psychiatrist included in that number. If you do have limits, find out whether the limit changes if you are diagnosed with a “biologically based mental illness.”
- Verify the billing address for mental health claims. WRITE it down.
- If you are asked, the CPT code for an initial visit is often 90791. Follow-ups for individual therapy are often 90834. You should ask the provider you wish to see what codes they use.
- Write down the date of your phone call and the name of the representative you spoke with.
- Here is your check list for your first appointment with most providers:
_____ Insurance Card
_____ Authorization Code if they gave you one
_____ Billing Address of insurance company
_____ Copayment (Check made to your provider, or cash)
“Out-of-Network” Mental Health Benefits
(What to Ask Your Insurance Company)
- Call your member services telephone number on the back of your card, and state that you wish to “verify your ‘out-of-network’ outpatient mental health benefits”.
- Ask if there is an annual deductible, and if so, is it separate from your general medical benefits?
- Ask what percentage of services is covered. Usually you will be told a percentage of “reasonable & customary” charges.
- Ask them to define “reasonable & customary”. Usually they will not give you a number, so in that case, tell them that you are seeing a practitioner who charges $250 for an Assessment (CPT code 90791) and $150 for follow ups (individual therapy extended, CPT code 90834). At that point they should tell you if these fees fall within “reasonable & customary.” They may ask the zip code of the office where you will meet with the therapist as the usual and customary amount can vary according to typical counseling fees in that zip code.
- Ask if there are any limits on the number of sessions, and/or dollars, available for your care per year, and over the lifetime of your policy.
- Verify that the credential, of your provider, such as an LCSW (licensed clinical social worker), is acceptable.
- Find out if a referral, pre-authorization and/or pre-certification is required to receive care. (Usually this is not the case with an Out-of-Network Benefit.)
- Ask if the benefits change if you are diagnosed with a “biologically based mental illness.” If so, then run through 1-7 again. There are a handful of biologically based categories such as major depression and OCD.
- Find out how to submit receipts and get reimbursed. Typically, with an out of network provider, you pay the entire fee at each session. You send the receipt with your claim form to your insurer, for reimbursement of what they cover.
Example: Ms. Jane Doe wants therapy. She calls and is told that she has an annual deductible of $250, and that 80% of “reasonable & customary” charges are covered. She verifies that the fees of the provider she has chosen fall in that range. She has a limit of 30 sessions per year, except if she has a biologically based diagnosis. No precertification is required. She attaches the invoice to the insurance claim form and mails it or faxes it in. Translation: Jane will not be reimbursed for the first session, an Assessment, which is $250, as it goes towards her deductible and fully covers it. For the second session, she is responsible for 20%, which is $30. Each session will cost Jane $150, and she can expect to get 80% of that back from insurance, which would be $120 per session.
These suggestions were adapted from a handout by Stacy Hoffer who is an in network provider with the PTS Student Health Benefit Plan – see information about the SHBP Specialty Counseling Network. Neither Stacy nor PTS is responsible for errors in this advice. The responsibility for your account with any medical practitioner is yours and ultimately, you are responsible for the fees charged. Unfortunately, most mental health providers in the Princeton area are not in any insurance networks so it may take research to find someone who is in yours.